The Firs' of A

. _ BTainin , Paul it.; k Others St%idy, on Dri v ng by S '1 Popu ns. Al Report, Volume 'Conduct .of' the-_ .ect,and State ,=of the Art. Tm_sTippTior. DunlapaniA'ssociates, nc.,Darieff, Conn;. SP.ONS AGENCY Bureau of Educationfor the Handicapped (DH.E.W/:0E)*. Washington,(Lit'. Na jo al Highyay Tra ffic safety Administration (DOT) , Waghington, FEPORT SO DOT-.-HS7802 329 PUB DATE . Apr77, CONTRACT__ DOTT.HS-..701206` 10T? 167p..:. Frpr relatedinfor AVAILABLE F Nat-ion e.1 TechnicalInform-

EDPS PPICE MFO 1/PC07' Plus- Pogta-g-a. DESCRIPTORS .Aurally'Handicapped:Cerebral Pal ..1-1 -0i7seas4.5: *Driver rcillcation; Emotionally Disturbed; FP1.1e.PsY; EgUiPment; Evaluaton Method-s;-*Handicapped; mental Tliness;' MPn4:ally t,feurologicallf - Handicappedt Physically Handicapped;.,'Special. Health Problems:- *State L'egislationts 'State iiicensitiq Boards; . - o *Traffic Safety. .,

The firs' ofA -volumereporton,m.otol: veh driving by handicapped :parsons focuses, on driving behavior. f -cat 19. types of handicapping conditions. Information is deta&led,,Feg drivereducation an& assesslent materials', present ste* regarding licenSing,-relevantmedical opinion regarding licensing and .axamination, com-plicating factors (such as theuseof therapeutic4 drugs) ,and private-and commercialdriving behavior for specific -. conditions, including the following: mental retardation, mental illness, neurologic and carebrovascular handicaps, epilepsy, - diabetes., musculoskeletal handicaps,. hearingAisoriers,thyro diseasei renal disorders, cancer, and obesity. Automotive. adaptive equipmer# 'is briefly coneidered monq 12 recommeldations. made. are. for a more comprehensive analysis' of the drliving task for, normal Itivars4 'a large scalp epidemiological studyto measure the acoidan,+. .and:7:Lolation sates of sc:),cifio,haUdicapped groups, and validat-d Asse,sSnient and evaluation oroc,edurs.. (CL)

*** *** ** * ******** ******** ***** *** Reproductions supplied byFDRS the boct- 4-!Ta.t 'he m from the origita document. ******* ****** ** ARTMENTOF NEALN, CATION a WELFARE AL INSTITDTEIDF EDUCATION ,

NT PIA_ BEEN REPRO- CT6T AS NECEWED -FROM DO.ORDANIIATJONDNIGIN. y. TINTS OF VIEW OR OPINIONS -0 1461" NEEESSARJLY RENJE. 'ICIAL NATIONAL INSTITUTE OF OS14,10N OR POLPty

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trout is ineilebie to the public through etionel InforrnetionSeri_ice, 22161 TO THE EDUCATIONAL RESOURCES .INFORMATION CENTER (ERIC)." . Prepared for the. Depar-ttnent of Tr iii-ghwalr -Traffic Safety Adrniiiist.c undZr doA't kae* ..,- nrq-FIS-5701206.,he opinibfist fill.in,gs;,_ Cod usita expreS'sed in this publica,tion art those 'Of th b r 4 not nece 5 S ray those of:the' Ntiona,14-Sighwayri-jf4icSakty,.. ,. . ation; . . ochrt. icI °Raport Documentation Pug.

P 2; GOriarliOnt ACCO1i Cln N. . `-cipifni'1tdtn / OT WS -802 329

jit!send an Svb'i'I . °repo _ INAPACf'STUDYON DRIVING BY S''ECIAL.. April -1977 6 Porforrning Organisation C POPULATIONS; FinalReport, Vol mer-Conduct'C A 'the Pr©Ject.and State of the Art C . '. O. Performing Organization Ragout No.

AL' 111 A . B r a ii-q.n , Thorn a J. Nau h on and kobertl.;l. BL.te ecove D76-10 -V. IPrfoeming Orgeriiii;tion Nome 4nd Address 10_Wadi Unit No (TRAIS)- Dunlap 4.11d Asso tes, Inc. D.Parkland Dr e 11 _ Controct or i;nt Nod ien, Coonecticiat 06820 DOT - -01206 Typ. prilepate and Period Cowered pan Agency -Nanoany Addeo U. S. Dept. of Health, Final Report- U' De of Trans. Education and WeUare June1975 tNovember197,6.. National Highway Trafilt Vureau of Education for: Sikty Administration the Handicapped 14. 'Sponsoring AgencyCod. 5 on,D.C. 20590 Washington, 13. C. 20202 15 opploreorilory . ., This is Volume I of a two -volume set prepared under this contracts

16.Abiiroc

T project was conceived to study the '-impact of motor reb.icle'ciriv-ing on the, -roadway-s---by--q-s-pecial-Populations.5-' Major-concerns were special -: pop n learning to drive, "being licensed to drive, and driving behavior:., a consideredfrom two perspectives: the impact on the handicapped' e and ihes a t on the welfare of the general public. - , The pr jct was divided-into-two phases, Phaselestablished ,a research -idata -. base, of information directly relevant to special population motor=vehicle driving. This-., in.forniation is summarized and presented in Volume I of the Final Report: in-rpact Study on Driving by Special Populations (Conduct of the Projectand S of 'he Art).- Volurne U - Impact Study on Driving by Special populations G ide f r the Evalu_ation of HandicappedDri4ers) draws oinforrna.tiorr c011ecte during Phase I and, ,/-nthesizes th se data into edict_ eprbdu4s:::- which will improve the circurnst es und= htch special populations dri.7.re. The second volume pies ets an aroac.. to the evaluation n-of the.license applicant who is. handicap ed which is eful not only for d licensing officials but also for driv educationd other pr.ssional involved in the rehabilitation of hariclicapp d..p_ sons.

1 7 .9Cey Words 18. D iu io f ant Handicapped Evaluation DOeUTI1 available to the U.S.', public Driving Special Populations through the__tion a-l-Technical .rrnance .Motor Vehicle, o i e ce, Spri_ngfield, Edu ation Driver Lirhitation , gis. -16 ,

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This project was conceivedi to study theithp.act of motor Ivehifle driving the public, roadways-t)y "specialpopulatIons.';'-,The rne.jor concaNns were. Special 4 populatica\s-learning to drve,tbeingi licensed to drive, (and driX,ing behavior-irri..-ti 'acta s' considered from two perspective th_edh-Ipact on the handicarlped drtvei- ., and irnpact on the welfare of the non-handicapped public.The il-npact on the haneTicapped fdcu'sed on pe rsonal -safety and mobility, issues.The impaeVen t -e

non-handicapped public focused en generalpublic safety and on the benefitst to a SOC_ -,letY with a mobilehandicapped population. The der,ivation t _ these perspectives canbe found in the gals of the two agencies sponsoring the p.-eject:The National-Highway TrafficSafetrAchninis-- ration of!rthe li.S. Depai ent of Transportatiorvhas the chatterfor saving lives. on the country's road. a This includ6s the safety of specialpopulation:driver s =selves as well as the safety other driver's, passerigers, and peciestrian. Bureau of Education forthe Iandicapped of the U. S. Department. of Health, cation and Welfare has a responsibilityfor; the training of.handicarip4d per including driver training, to ensurethe opportunity for lives' and careers, fruitful_ and worthwhile to themselvesand tsociety.

oject -was' phase's.11-ic purpose of Phase 1 was.so, sh a data cit all tly relevant Info.PrilatiOn.During-__PhaSe II, ALIA:zed tik develop pruclucts which, areiran-lediate Ey useable and -3.prseve nces under whichspecial poputationS drive.: Th6 products prodUeed lie tilt-project areOistinctr}r,different and'constituted '61;rr-yes I and I1 of the Final .Report.The first. volume describes the wealth of -rnation c-,athe red in Phase I. as well as purpose and conduct of the total. -study:.41111-e 5Qcopd volume, presents an appioach tothe evaluation of a license applicant or. perspeetive,applicant4 whoishand(eaPped.This document, how- ,ever, contains information.useful'notonly to license officials but also todriver the rehabilitation of handicapped education and Other profe_ssionaLs involved,-.in. driver. 4

THwAY !RAFEIC SAFETY ADMEN IS TRA T I Of) t,PREPARE FOR' THF TYPO- LFTRA..'r-tIR TA , :1P:; 'A!0.!:ig AN- ; COM; Lii50,r; w.CREC:IE t,;NDER COnTRAT:i LiOT - IS D-pjZ06. 7 tiOZE Cr °THE';fi111%AL ; THIS Pr.AL i CA ON" ARErtiOS!(It I vf, t7;k0F4Z "41..)1 7;LUES5 AR ±1.'l tilAFF I ,Ft- I): ADM: 5 IRA 1(A." , , The Nationa hy Traffie'Safety AdMinistration (NHTSA)and the Bureau cEducati for the Handicapped (BEI-I) sponsored the study on the impact-1A driving bspecial populations.The term,uspecial.populations" was broadly- defined, to include those peopleWho 'have physical or. mental - .- handicaps which could affect their vehicle 'driving capabilities..The concerri _of both NI-IT&A. and 13 -"was to study the catiplexissuesHof' population driving with the ultirn to objettives'of incre*sing public appfety'cA the nation's higlr.Va:ys and of hiker asinethe riibbility of all citizens.Aid. presekif -project addressed thege complex issues and provided detailed information in'adVancing the etate-of-the-art of Icnckvledge inis`eld.. Thisi knciit;ledge can lt e directly applied to the improvertient of drive educa _oaiidlliceniing of. special papilla- ... Lions. . . . .- Two °M_ c documents were produced_as a reatilt of "Impact Study on Driving by Sp dal Populations. 1'both of the c19.6iti.ents are volumes of the Final Report.Volui-rie` I is a description of the project and at compilation of current thought on speciarpopulation4I'driving. The current inforthation ill- eludes drivee education, driver assessm'ent, driving performa4ce, .arid driv.er licensing.Volleme II is a gui e.for the elaluation of handicappecLihdividuals who are planning to drive. Direction and guidance for the project was provided by Dr. Harold Booher, ntract Technical Manager, of the National Highway Traffic Safety ation, and Dr. Max Mueller and Mr. Melville Appell of the Bureau of EdUca- tion for the Handicapped.- Thoughtfulsuggestfons and comments were contributed throughout the-project by Drs. Jan Eberhard, Jerry Tannahill, Michael Prerel Les Moore, and George McDonald of NFITSA.Discussions witlyDr. -Edward Pizer, Mr.- Anthony Staros, 'Dr.FraWnk Schaffer, and Dr. William-Holzbeig (4 the Veterans Administratibn- were also helpful. The project was difected at Dunlap and Associates, Inc. ,of Darien,- Connecticut, by Mr.. Paul Brainin'.Mr. Thomas Naughton and Mr. Robert., Breedlove, members of the prpject staff, contribnted greatly to the prpgram s accornplislu-nents.IvlrJoseph Fucigna, Executive Vice-President, served as responsible corp officer.. Dunlap and Associates, is especially indebted to the consultants to the project: Ms. Elise Brown (aided by Ms. Mary Barber), Mr. Jiri Sipajlo, -=Toseph-key-noIds, and Mr. 'Frank Gentile and_ Dr. Gerald Manus-of Hurnah Resources Center. We are also-indebted to MSfshall Franklin, M.D. , fur his

. as We are also grate all tnose in Lviduals andorganiiations,too numerous to_rnentioni who upplied.uswith valuable information.This "iiiiorrnation.wais assimilated andused as a resource for bothyolurhes of Report.. DUCTIbN packground Definiiio'n of "Special Populations" Ter general Lisnitations of theStudy' et:INDUCT OP THE PROJECT

114, DRIVER EDUCATION AND LICENS 'SYSTEM MODEL

IV. .REVIEW. OV THE DRIVER BEHAVIOR OFSPCIAL POPULATIONS Description of the Driving Task The-Review of the Driving Behavior,Lice nsing and Driver Education Literature for Handicapped 7

Undifferentiated Han Mental Reta' rdatioli Mental. illness Suddep. Illness, Neurologic and rebrovascular Handicaps Epilepsy- Diabetes 7. Narcolepsy Vertigo -9. Cardiovascular and CirculatoryR(.seases 10.14 uscujoskElleta Handicaps: 11.- Hearing Handicap 12: Respirit4ory conditions 13.Adrenal Dise'ase 89 14. Thyroid Di ease 90 15.Parathyroi Disease TABLE OF CONT (coritLnued}

16. Pit land Dise: 17. j Rena Disorders 18. Cancer 19. Obeaity.

Auto Live AdaptiveEquipi

RECOMMENDATIbNS. Li4TROPU

A.Backjiround This ,project was conceived td motorvehicle, driving on the public roadways b4 "special po pulations,,,T e major concerns Were special .

learning to drivk -being.licepopulatidns nsed to drikieiadriving behavior. Im- pact was considered from tw.o perspectives: the impac e handicapped driv'er and the impact on the welfare of the noarTa:rwlicapped'plublic-. a mpact'on the handicapped focused on personal safety and mobility isst4s._ e, &Tact on the non-handicapped publiF focused on general public safett and n the benefits to.a society with a mobile handicapped population.

The derivation.i of these perspectives can be found in the go of the two agencies sponsorinig, the projectThe National Highway Traffic Safety Adrriiii- istration (NEITSA) of the U. $. Department of Transportation has the charter , for saving lives ..ono the country!s roadways.This includeesthe safety ofg'sPecial opubtition drivers -tliemseives as*well as the safety of daledrivers,, passen- _gers; and pedestrians. The Bureau ofFucation (BEH) for' the liandicapped of ' the U.S. repartrnent of Health,. Educatidn and Welfare has aresponsibility for the ttaining of handicapped persons, including driver training, to ensure the op. pbrtunity-for lives and careers that are fruitful and worthwhile torthemselves and to societyOther agencies,' such as th` Veterans Ad inistration, although not an, active sponsors of this contract, are potential bene actorsof the results. ed- The Veterans idrninistratiorf,i-s-actively involved. and concerned with driver ucation,licensing,..- and the driving of disabled, veterans. priving itri our society is as important, or more important, to handicapped persons as it is to other segmentsof our population. Persbnal use of,an auto-' mobile is often a7 determinant factor both in employment and in thesatisfaction- of the basic human needs, from food, acquisition to the psychological and social requirements of everyday life.A person unable to drive in our mobile society f may lOse the opportunity for- personal freedom and independence. FOrthose who becorne disabled after once having lea red drive-, re-learning may be a signi ficant part of their rehabilitation. r With access to an automobile, andicapped individual who is unemployed may be able.to obtoin employment. 'T e Abt study(1969) reported, that at the time at-their reposrt, only 36% -'of the national liandicapped population aged 17 to 64 were members of the laboi--force.This compared to 71% emplorrient-of the non-ha ndica'ppecl popuiaation of the same age group.Not being able; to drive is one of the many Obstacles facing a. hand.icapped.person who wants employment. dependent on society thehandicapped are, 'the more they in general, the less Certainly this contri- are ableteeontribute to the welfareof their country. bution has a significanteconomic component.Initead of a cost to 'society, theksbecorne an asset. The ext&it of the economic impactis.pa.rtiaLly determined by the number of people who are-handicapped.Is 197Qthe President's Task Force on the Physically Handicappedreported that pre'cielinform\ation about the numbers, location, and categories of thephysically handicapped, is not available.The '- Task Force estimated,that, as of1970, over 25 million per sons were handicapped. At least 20 million personswere' judged to require some assistance h approximately 14 million personsthought, ro be suffering from some major limitation. There are e-also costs associatedwith driving and driver education.Driver. education, for instance,requiresallocation' of resources,- often- from the'general public.Th.e4-imary cost of driving, however, is related tosafety. 'This, is'' the societal Cos-'from the loss ofhuman lives, human injury, and propertydamage. Therefore,. in the determination of whoshould drive, one must consider the general welfare of other people onthe road as well as the rights and needsof the individUal driver;. Since the impactstudy results contained in the two volumes of the Final Report discussesthe driving of a significant number of indivils, the report has a potentialeffect, directly or indirectly, on most people in this country. The project wap divided into twophases.The purpose of Phase I was establish a data base of all directly.relevantinformation.During Phase II, this information was utilized to developproducts which are immediately useableand which improve the circumstancesunder which special populations drive.The two products prdduced bythe project are distinctly different andconstituted Volumes I and II of theFinal Report.The first volume describes the wealth of in,formation gathered inPhase I as well as the purpose and conductof the total 'Study.The second volume presents anapproach to the evaluation of a license applicant or perspectiveapplicant who is handicapped.This document, hoWever, contains information useful not'only to license officials but also to driver education and other professionalsinvolved in the rehabilitation of handicapped drivers.FUrther discussions of the end products of the programand conduct of the, projects can be found inSection II below.

B.De on e ial P 010 Terminology varies considerably amongthe various disciplines concerned with "special populations" and evenvaries from study to study within adiscipline. Throughout this Einal Report, the specialpopulations to "handicapped, " will be used in the sense in which it isdefined below. The contract for the present study stated:"The definition of the handicapped individual is broadly defined by the Office forthe Handicapped (01-1-1) as one who has a physical or mental impairment or conditionwhich places.him at a disad- vantage In a major life activity such asambulation, communication, -elf -care, socialization, vocational training, employment, transportation,adapting toousing. The physical or rnetttal impairment 'Or conditionmust be staticv. of long duration, or slowlyprogsressi It is useful to Make thedistinction between condition, impairment, functional limitation, disability, and handicap. Acondition is a description ,of a departure from a' state of physical Or mentalwell-being (U.S. D. H. E. W. ,1974). The condition (or disease and injury) residuals arereferred to as impairments, relating primarily to abnormalities in --physical and mentalstructure and functioning. The activity losSes 0,t- restrictions _resultingfrom impairments are referred to as functional litnitations.A disability is a functional limitation in a majorlife act vity.- The term "handicp" is used in referring todefects and limitations imposed by disease or injury, as well as to socialdisadvantage. Handicaps are frequently referred to as Limitations an individual has orhas not overcome.In this sense,' handicaps may be considered as competitivedisadvantages.The individual may retain-or develop the ability to cope with theenvironment, by minimizing the extent of incapacity or, moreaffirmatively, by pptirnizing the use of his residual capacities.Hai-raicaps presuppose the existence of animpairment' of structure. or function but not necessarilyof a functional limitation or disability (Haber,1967)

C. Genera the Stud Ground rules were established at the initiationof the project in the Prelimin- ary Work Plan and subsequentrevision to the Plan as well as in meetings with NHTSA and BEH.Theae rulecreated boundaries to the scope of the subject matter of interest in the project.The boundaries allowed the concentration of the project resources on the handicapped groups ofmast interest,.Those groups, deleted from concern in the project, weredropped primarily because they were and are subject of specific study in other programs.It was thought unnecessary to duplicate these other programs. These groups are The elderlyThere are persons considered as a groupsolely as a consequence of their advanced age.However, most of the impairments that these people sillier-from are covered inthis report.

-3- Drug abusers -- This'includesall use of alcohol and other essentially non-therapeutiC drugs as well as over-useof therapeutic drugs.This paper does report; in alimited sense, on the effects oftherapeutic, drugs. School dropouts--lhesz peoplewho, because of their dropping-outof school, are considereddisaavantaged. However, people who have physical or mental' impairments (e. g. ,mental deficiency) and then drop out of school a:re of interest notbecause they have dropped out of school but because oftheir impairment. Visually impaired--, These are personswho have a variety of Vision. impairinents. VisiOn, in'the Currentstudy, is only considered when it is a manifestation of amedical condition which causesother impaire menin addition to vi(I ones. Not onlyere boundariesestablished which affected theselection of hindi- capped groufor study, but also boundaries, wereformed concerning the relevance of, udies which were reviewed.There are many disciplines or areas t impinge upon theconsideration of driving and handicapped per - of researc medicine sons.Th are the general areasof traffic 'safety, education, psychology (particularly studiesof psycho-motor capabilities.of'impaired per= ology, etc.Studies in these areas maydiscuss driving-'or educa- sons); phy, driving or education, and they maytalk about handi- tion but no handicapped made caps butt relate them to driving ordriver education. No attempt was to review U of thesestudies.The studies of most interest werethose which the combination of both driving(in any aspect) and thehandicapped.' eonsidere studies of The ernphis in the review of theliterature was upon the specific handicapped dyiving behavior, driverlicensing of the handicapped,and driver education of the handicapped.However, thestudies reported in the Filial Re- port come from these manydisciplines (and,others) and reflecttherepets - tives.In addition, many studiesof a general . nature were seen,Jput usually not referenced, H. ,CONDUC'T OF TIME OJE T

This section describes, briefly, the conductof the project through the two.- phases, culminating In Volumes I and H ofthe Final Report.The highest priority throughout the conduct of the project was to provide documentedproducts which would have the greatest influence within the contract'slimitations, in creating an optimum driving environmentfor special populations. From the perspectives of NHTSA and BEN, the optimum drivingenvironment is one which would allow all capable,handicapped drivers to drive safely.. As a'result of the priority and prevailing viewpoint, the work of the project was concentrated in dstablishing the state-of-the-art of special populations'driving in Phase I (and contained'in Volume I) and in developing A Guide for theEvaluation of Handicapped Driver in Phase II (and contained in Volume TI). The project officially began with the contract award in1975 and_ acceptance. shortly thereafter of the "Preliminary ProjectPlan." A meeting was then held, at NHTSA with the major Dunlap and Associates,Inc., project staffNHTSA's Contract Technical Monitor and other intestedNI4TSA personnel and a representative from BEH to discuss the"Prelfrninary \Project Plan." Following the meeting, the r'Revision to the Project Plan" wassubmitted and accepted. Work then began on the major focus of Phase I, a reviewof,the literature and expert opinion. The project staff colledted the following types of info ion in Phase I: Experimental and controlled research related todriving behavior and performance of the handicapped--there was notmuch of this information available.Most that was available suffered from poor designand execution.This made it difficult to integrate the information sincethe data was often contradictory. Experimental and controlled research related to drivereducation and licensing of the handicapped--there was less ofthis information available than the data mentioned above, and the difficultywith its interpre- tation wassixnilar, Case history and expert opinion related to drivingbehavior and performance of the handicapped-7there wasquite a large quanity of this infor- `mation aivailable.However, it was, by its nature,' subjective, andsub- jective data is difficult to interpret.

-5- Licensing and education hda rds,. regulations, and guidelines.. related to driving for the handicappedthisinformation was collected from the U.S. and from several foreign countries. Statistical data related to the handicappedsomestatistical data was collected.Unfortunately, more statistics that were- available were ill complete and inconsistent. A typical problem wasin the definiiThri of a handicapped.Data from different sources concerning a handicap may vary by several magnitudesdepending upon the definition-and assump tion made. Driver educational materials for the handicapp s_-included les sQn plans, instructor gifides, student manuals,workbooks,supptvrilie course- information, and instructional aids.Very. little .of, this L,hafisi.betn published.Most that was available at all-was. loaned- to Thepfr,o,ject.In cyst cases only descriptions of programs were a Assessment devices related to driver andensing of the handicappedsome informailoi-rvaof hese devices have been used for evaluating and screeni g people or,edu ation programs, for evaluating during education programs,for evaluating successful completion of educational programs, or for screeningfor licensing.' Few of the devices have beenvalidated for their purported use. Four approaches yre used to collect information onthe state-of-the-art of handicapped driving. hese were:(1) acquiring opinions as well as the pub- lisped and unpublished materials from theproject consultants (a911 exprts in their fields), (2) .acquiringthe- opinions and materials from other experts ando' f- ficials,(3) running computer literature searches andacquiring appropriatedocu- mentation, and (4.) seeking other references torelevant documents and acquiring these materials. Lnvaluable assistance was renderedthe project staff by the project consultants.Drawing upon their own expertise and knowledge,they contributed useful opinions andrecornrnenc=on:.Th"------) y a so assisted members of the project in assessing and interpi-eting th materialscollected.In many instances they were. helpful in locating and secure g copies of studies(both published and unpublished) from personal librariesthat would otherwise have been unavailable. - The Con-c sultants also provided leads to other expertsin the subjectmattet. under inves -gation. Hundreds of people, prominent in the areaof the handicapped, driver licensing, driver education,. and driverbehavior were contacted by the project staff. eis

-6- Their opinions, research studies, relevant dila, curr were Fs The following represent- the type's of -organization tt we rcontacted: a Associations for the.handicYpped and other .professional associations concerned with the handicapped Unive rsities Research firs Iristitutr ns and schoo(public and -pri rate) Prominent individuals in related fields not associated with any of 41e above or no longer involved8in related work Computer searches were used to scan journal articles,books and dis a- 'dons. to identify relevant information for the project.----ft waspossible to ar- literally millions of individual reports to find those suitable.The following computer 'searches were performed: ERIC--ThiS is an.abstra.T; index th4t primarily covers the fields of education, educational chology, and psychology. Psychological Abstracts- cover the fields of psychology, sociology and related areas, Highway Safety Literature Data Base--This data basecontains the literature concerning the highway traffic safety fieldand is multi- disciplined. MEDLINE and BACKTILE-- These contain threeabstract indexes the medical field:Index Medicus, International Nursing Index, andIn: der to Dental Literature. CEC--This is the Center r ExceptionalChildren Index srnul ciplined iNTISThe :ional Technical Inforrnation,Serrice Contains an index of gove rnme'nt reports,*

\SSLEThis is the Smithsonian_ an ScientificInformation Exchange which `contains information art.both government and privateiidustrialcon- tracts and grants in progress or very recently completed. Once, having obtained these basic' citations the poject- staff the cquirec1 the actual referenced documents froth librarises;institaions and personal files. This material, in torn, led toother references and citations which were similarly collected. As a crosschec-k on the literature thusaccumulated ?.nd to assure cothpleteness, the Science Citation- a was a.lso acre sed.Very few relevant new articles were found,ateestino thethoroughness e original rch: 'Emp was 151a.ced On re s 'a formation for the period beginning in ,960 ". .d continuing through 1976, altugh prominent articles before 196,0 we-r review.ed.the,iriformation was collected from. many countriesthe-United ---.' states, Cana,.da,, 'We gt Germany,. Great Britain,Israel, SWitzand4 'East Ge r-. many', Russi.,we:: en, Denmarls, France,Finland, Australi and others. Those arti.--le8, not. availa.ble in English weretranslated.The s 'Of this effort 'wok an:exhatWive coRection of informationconcerning the impact of -sfie 7 ei 1 po -atiOns dn'driving.. .0 , . = , to present this ior nation in an orderly ashwn in the Final'Re- pbrt, the' handicaps had to be organised, into meaningful groupings.The objective was to classify the handicaOs in a methodical manner.Toaceomplish this, a number of disease'classification schemes, disability surveys aid guides were collected and reviewed during Phase I. representative number are listed below. ,

American Medical A ssocia n Physicians guide, for dete dr - ver limitation.Chicago: American Medical Association, 19'73. American Psychiatric As-soc ation,- nost c and Statistical Manua Mentalisorders, 1968.

Canadian edical Association, Committee on Emergene Services. Guide sicia.ns in de.termint fitness to driVe a moor vehicle. Ottawa: Canadian Medical A ssocia 1974. 'Haber, L.The idenhe measurementA of functional cacitlimitations.Soci =1ecurityt`s.urvey of disabled, t 1966.Report No.-10, July 1970. b- X- Kay, H. W., SI Newman, J. D. ,Amputee survey; 1973-74: Preliminary findings and comparisons. Or hotics and Prosthetics1974, /28 (2), 33-48. Nova Scotia Medical Society, The Committee on Traffic Accidents. Nova Scotia guide for physicians in. determining fitness to drive a motor vehicle.The Nova Scotia lviedical Bulletin, May 1966, 3-12. Quebec Ministry of Transport.Medicaf guide to determine ability drive aBator vehicle,Departent of Transport, July1973. po-oulation:....-1 70sub'ect_ Orklisability,

USDHEW, Office of Human Dev.eloprnent, Reha ilitat oner;iices Adrninistrtion.Statistical're or :.s tern coding of disabli . R.ehabilitatOn Services Manual, 1'974.

.4 USDHEW Public Health,Se rvice hth revision, intern- -o 1 clazsification of diseases ada ted in the United S Nolan Tabular' is 1967. USDHEW, Fblicealh Se vuiceHealth ResourceS Adrninis. trat Cu es e.s the health interview curve United Staa, .7 1974. Many authors have stater that up..to now there has been a greadeal 6f conceptual-coniusion in the terms, -used to ident-ify and classify disabilities(Haber, Nag i? '1975).Even .a ci,Vsory reviereveals large inconsistencie.s inthe use of theAerrris illness, endicap,di ability and irnpairment. As Slater,(1974) has pointed Out; working .definitions- of disability must varyto accommodate the rtive 1egar.,-e63nbmic, medical, -i.n.d.social purposes.F&r rl tans in, hospital record-keepingin this country, the JriternationalClassification of Dip- eases (accepted as astandard'of-classification foernortality statistics) had 4.. be adapted in order to ma..intairv=statistiGOn morbidity.. The USDOEW, Social Security 4;dministration collects "disability" data ontheincidence of work-im- pairing-disabilities which specifically impacts on its payment of socialsecurity ..insurance.The National Center foAr Health Statistics (National Health Surveys) t\colliects "di-sability" information by it'definition on pathology and irnpairnient but then only for certain populations. 'A specific handicap has manyim.ensions (e.g., anatorni.cal region of disease process).The prisicipal dirnens-on oxen as an axis of classification is.clependent uponthe intended use bf the A classification scheme has to be and rstandable to the people-who will use., it.- Tha,major reCeipents of the Final.Repor_t_will behighway safety, licensine, ,ndredtication personnel. There are five general_ types ofpersons who .will be ajor users of a classification scheme for liceasing thehaAdicapped. They are the `pi:tensing lawrnakers, license examiners, medical adviwry boards, physiOans, and the handicapped themselves. These people need to be able toclassify individuals or themselves) to develop and interpret licensing regulations.Curriculum designers, special education che rs, d riveeducatan instructors, and the handicapped themselveS, will be major users of a clast -scherneutill- zed in edikation.'. Th e y'riced to-be able toclassiTy and understaind handicapped `people to ol-be abli) to :dev0"op andlea.efa d educallonitrothein.' The feasibility. of classifyinghanLieips according-to relevant functional liitatiOrn ns, orfunetiOr capabilitiesc was conde,red.The most relevant functionallim- i tations,ur capabilities, co . to ,relate.to blia.Viordurg dri- . , ving.However, to relate this to driving b ha.viorspecificallywas This would require'detailed'information ofthG driving taSk--theperceptual, cognitive and mc-itor compdnents of _driving.Th0,4ciformatien -does not exist in much detail for the,able -bodied or=the.:handicappect driver (seetSec1ien IV Of this--report_ for a detailed cle s c riptiop of the driving task):Evcri. if this form of classifying hanclicap,,,- werefeasible, if could be trouble.some to the poteri- tial uscrr.of the inibrmation, educat.Lonandlicensing pe rsonnel, 'Mho ere using other classifications.Currently, a medical conditiclri celassifica.tion scheme most prc_vclarit. condi issifica system describes disabilities froj clisea9 e perepo,cyve. e. g,, cardiovascular disease, epilepsy, diabetes, etc. and educatien pec-,. 5t o iv _ this Approach cprre:ntly:being used by licensing s, but it isgenerally how- releVant resea,irch is described. In order toirys tea the informatic,bn,collected in the'proct meaningfullyand to fa.cilitate ifs applr;attern,the (iassification scheme that has been appliedin Volume I anirl II ofthe -port iOt the metclical condition variety;

ss iOneefica,,, on _me was established, the information.gathered in J-cscriteclin a prelimicnary form in the' Lnterrrn gepqrt." The conte_ the Interim Report was the subjectd'a meeting which was attended -by rnerqbe of the Dunlap and Associates,_ Inc. project staffand representatives. erf N-FIT,Sil, Bgli, VA and other organizations.It was decided that since the Interim Report was not an officinal projecidocument (only a working paper) and sin'tzu it was in a preliminary forth that a finalizedcomplete version would be procluce'd in Phase II of the project and appear in the FinalReport.The des-, cription of the data collected in Phase I can be found inSection IV-of this report (Volume I of the Final Report).This section presents the Information but does not draw firnaconclusions from it.Ln a sense, the conclusions can be foundin Volume II (a Guide for the Evaluation of Handicapped Drivers).Volume II was derived from the interprptation of the informa.tion collected inPhase I.It-is expected that the redaders of Volume I will have many different reasonsfor seeking the information 'corAined hereinfrom medical'research to driver education to licensing.handicapped drivers.Each-will interpret the data for his own interests and needs, and each certainly, will want to collect more detailsfrom the original studies.All studies are fully referenced in Section VI, of Volume I, -10- _. At the completion of phase I, these was an Opportunity-to select target oups for further study in Phase II arid to plan the. best' allocation of remain- 1 ing resources for completion of the project.The prpcess of defining the state- of-the-art:during the first phase' provided the "database for makilig these decisions for the"'seci5nds At thisiztyhase. in the project, much more astute and sensible decisions could be madean were the preliminary judgments in the initial Work Plan., Although a feasibility (cos )/benefit discussion contained in the Interim Report suggested the senction of all or part ofsix specifjc handicapped-groups for additional work in Phase II,t was decided that amore g'earal final project product would be the most beneficial.(The feasibility/benefits discussion was based upon prevelanee Statistics, data on driver performai:ice, dafa on drige. ye r education, 'information onliceti:Sing and other relevantfactors.)' The general final products were to treat, and they have, all handi'Lppea conditions covered in the Interim Report.- Many, target groups, then, were "choosen rather than a. selected few as it was initially-conceived. The completion of the major 'encl-products of the prograniere thesulojeCt of Phases II.these- roducts ire contained in the riviD voliames of the .Finl-Re- port,. although some of the following products wete begun if). iA\iase I-,they were not complePed until Phase II.These products are (not necessarily in this order or addreS'sed separately as distinct sub-sections in the Final Report):

Annaly-sis of data on driver education and licensing An analysis 6f'data, On fandic apped drive rs An analysisf driver educational techniques and rr aterials An analysis of driver assessment instrumentation and methodology

A del driver'licensin.g and education system

Specific isle ation and evaluation of assessment devices Identification ofpecial-t-a-rgeti-groups Identification of driver functional operational deficiencies Identification ofspecial equipment Recommended4ri license standards

Guide lirreS f administering driver Licensing examinations

Identilic'ation fureher research and development Description of purpose and condct of the program All Phase II activities were completed over several months with an emphasis on Volume II of the Final Report.(Much of Vol tam was completed in draft form in Phase I.) Phase II activities were conducted by 'Dunlap and Associates, Inc. pFojeet staff, project consultants and with assistance by various other experts in the field.The reader, is directed to the introductiOn in Volume II Mr a detailed - description of that documentand its use. AZ -A DRIVER EDU,CATI N AND LiqE SII4G 5YSTEM .MODEL -

section des.cribes, in general, a driver education and licensing Lys em for the 'handicapped motor vehicle dperator. :This system, as proposed, outlines the processes a person who has a'z-nedical problem 'should encounter in obtaining legal authority to. operate a privat6...rribtOr vehicle on public highways. To a eel.- tain amtent it is 'am idealized system., yet it,was designed to be.practicable.It is. practicable;wit& in the sense that it r equire6`no new 'technology for implementation, and mast portions of the ,system alrea y exist In the States; althougfh the system as q.xi.rhole does not. This model; is presented as a suggested systerg for liconsing anc4, education iciats.. This system will allow them to utilize the information contained in Volume I and, particularly; Volume la of the Final ReportIt helps put into con-, text the appropriateness of the data in this rpport... The systerrY.'itself, is intended to allow' for the fair and-equitable processing of potential' speciabpopulation. drivers and to riot restrict !their personal mobility unnecessarily.On, the other hand, it emphasizes considerations of Salety for both the general public -and the7andi_capped.-l a In the current legal and social milieu, the right to mobility makes.this4;,;,, system model timely.Over the past few years the goal's of driver liclApsing have .13(f.en re,- examine"c1.The re-examination has beme rnoye,critical recently following court decisidns holding that access to a drerrs license is more. a right than a privilege. As greater numbers.., of the population grow older, as automotive technology advan ces,a,a_nd as special interest groupS apsert the'rights of their constituents, there will be inc reused. pressure on licensing administration and-driver education to,modify existing licensing procedures and education progiams, to insure personal mobility . Present state licensing adininistrations,,Obtain their public safety charter through a set of statutes-u which are usually very general in nature.Lssentially, these statutes, prevent the issuance of a driver's license or renewal of a license when:' A person who is suffering from a_ mental disability or disease is not stored io competency at the time, of application.

A pe9n who has a.physical or mental disability is not able to operate a. metr vehicle safely. t. A person a habitual-user of a,drug-eluding therapeutic drugs which renders him incapable of safe driVing. dtdr Vet-Ade adiriirLiSt _ On's, states, are empowered, and directed by la deVelop and ii-nplernent licensing-aroceddres to support the general statutes described above.in addition, the Le procedures need to treatindividual driver applicants in,at least, a consistent manner so that the licen'sedeisions ria-ay 15e upheld in the courts when they arechallenged. .There is another pattern of legal reasoning- emergingwhich further complicates_ the situation.If a driver's license is issued in a routine mannertd a physically or mentally impaired person, without duca'regard forthe potential driving hazards, the motor vehicle administrator may be held liable for dam4es or injurycaused by this person. The achniniatiator will probably not be held liableif there was evidence that reasonable administrative discretion was exercised.Any driver liceusing system, therefore, should treat handicapped drivers in aconsistent, -fair, and reasonable manner so-the licensing deciasions maybe tipheld-in the courts. Perhaps the most straightforward method in treatinghandicapped drivers consistently, fairly and reasondably would be' the application dfspecific medical fitness criteria related to dri-ving.Unfortuarately, at the present state-of-the- art of. information, it is impossible to bethat specific about the criteria. fact, Volanti E of the Final Report; A Guide orthevaluation 'of Handica Drive-rs, has significantly more detail than any guidesproduced previously. This,' however, does .not release the state licensingadministrator from the task of developing and promulgating lice4se regulations,.Asa consequence, Medical Advisory Boards (MAI3) have been given the jobs ofcollecting-information for developiag.criteria, of providing guidancefo licensing personnel, and of applying expert technical,judgernent to morecomplex individual cases.The needed 'flex'- bility in individual judgements of a handicappeddriver's capabilities by MAB's has been usually accepted legally, since most of thespecific medical fitness cri- eria have, been unavailable. The:judicial and legislative effect upon specialpopulations' .driver education has been oritented mostly to theyonnOrodriver.This has primarily taken theforrn of requiring equitable-public education, forhandicapped children. _,Driver education has also been available to veterans, who are in need,through the Veterans Adminis- tration as part of some rehabilitation programs.Other driver education programs have bee-a,available through private and charitableinstitutions for primarily the mentally retarded, the hearing imitaired, theorthopaedically and neurologically impaired. Few educational programs are available for peopleWith other medical conditions such as cardiovascular disease, mentalillness, epilepsy, 'respiratory disease, etc.:Little rernedlal driver education is offered, either., Generally, there appears to be a much greater need fordriver education, particularily in the over-school-age group, than can be met byreadily available servicea'.a

-14- r s N Anideal, practicable model should fit into .the current trends in education and licensing yet should optimize their advantages.The model does this.In describing the propostd syst rn, the general roles of the participants will be discussedt first. These are the res as they should be defined in an operational system, not necessarily as they exist today. Driver/special education personnel in-schools -- These persons will train the young, - belting_ handicapped driver while in school. The--- driyer training,will be a part of the basic educational program. The training will begin early in school, and eiraphasize both the safety aspects and the developinent of the needed skills.The driving instructors,thernselves, should he specifically trained to teach the special populations, they will encounter.If needed, the driver educators will be supported by special education personnel. pedial education personnel in rehabilitation centers and ins iris (public and private)-These individuals will be similar to those"described above.. However, they will be more specifically trainecl_to handle the types of specialized clients within their insti- -tutions.En-addition to' young drivers, theY will be involved in the training (and, therefore, rehabilitation) of older drivers, some of whom have driven prior to acquiring their handicaps. Driver trainers in private driving schools- -These trainers will serve a similar function to those listed above.They will train both young drivers and older drivers.Their role is to train those people who do not have access to driver training in, the schools or institutions or need specialized training not offered there. Driver license examiner (DLE) or supervisor, or specialized handicapped driver j.icense evaluator--These are the people, knowledgeable of evaluation of handicapped drivers, who form the front lines of driver license evaluation.They will initially see the handicapped driver and screen him according to guidelines supplied, by the Department of Motor Vehi- cles (DIM). He will either grant a full license, grant a restricted license, deny a license, or refer the driver license applicant for the collec- tion,.of additional, inforthation, or for a more specialized evaluation. Driver improvement analyst (DIA)--He is more specifiCally trained to -evaluate and assist handicapped drivers.He could fill the role of a specialized handicapped driver license evaluator referred to above, or he could handle the more complex cases for the driver license examiner The DLL,, -the comild constitute one rr al option e to the DIEL' lie willis c assist the handicapped Orivass vivo have pecial Troblerrks, such nee d for, help in ac diiv-er echication prtive trfehictatar cont Licogise administrative staff- -Ttis group 01 people withl.ei the driver licensing agency wig have tie primary- re spansibility for zetraisiing tralizecl data on hancli_ca.ppeci driersiy tatitdicap`groul a.rid by 4nclividtial clrivers. Ilia data Arill be colle-cted for tVhr v -rea20138:(1) the g.roup, data can be used dete amine relationships betweem lathec in_c haat:lick:1011g conditions aria] a.cc ide nt and violation rates; armed. (2) thft individual-data can be use_ful in rrialcimg renewal.liven sing dec sions fear izdavi c ua Is(i. e., changes or rerrioval'of license rest ritions ancl revoca.tion of licenses alt together), Medical ,advi gor y boa, rd MAE* -The 'medic aladviscry-boar-dpersorinel, consisting of apiropriate medical and highwaysafety personnet, -will harp two primaxy re gpo -within the State:resolution L.11-- diN.:riclval case 4 a..uicl determination of additional licerise medicalguidelines and medical criteria. 4 tie resonation ofindividualases, the l4AB will receive re ferrais groin (drive J. irnpJovernervt ama.lysts,driver license examiners other- specialize d evaluators. M.AB will collect _formation on individual cases frerra_ D3LE'sand D3A1 s as vial as' private physicians .arid / car public lie al th elepartrient pe rs o a.lorLg with driver record information, if available .. setting new lie standa.rds for specific raedica.1 ploblerns , they-Will receive and intpret data from the license aclrninistra_tive staff,as we ll aS iroan ether sources ,siacli as independent research s -tudie s and data f Porn other states. private physicians armed public he altli departme ritphysicians -- rhe se per sons Will supTly- in_fornation tolicensing pars ennel (ID 's, DIA' s, MABls) concerning tb_e extent of an._applicant' s c onditi on.ri a private physician is treating an applicari.t,then. the inforination may come _Troia lf, on the other hand, the applican_t 1.1 as no privatephysician, he -may ele ct to he examine. d lo.y public healthphysicians for diagnosis and evaluati on of his heal-th.Info rinati on may also be supplied to driver education pees rine1 te aid therm in deters-nit-ling the incysteffective method of drivet raining, Motor vehicle inspector --lie wall have the xes po of initially checking, and peri odic ally inspe- c tingthe integr it y of ad aptive c out role -used in -vehicles to will ensure that all vehicular d-vic es criticalto

-safe dri-ving are in. proper we rking order and are securely lasteried to -the vehicle.He will o deterrnin-e II the devices "-meetoperational standards for gush equipment.- DIVtlf and other traffic safety-research personnel- -These are persons, specifically, trafnect, who collect and analyze data on special populations.They either work directly fQr the -Department. of Motor "Vehi- cles,. or work for the Federal Government or private institution or corn- parkles,They will acquire data froxn the license administrative staff, or will 41.1e ct information separately iii their own. experiMents ar pro' je eta. goilie.; policeand e i.ergency personnel--They will be trained to detect hancli- capped drivers who have been involved in accidents.Both will be prepared in an,accid'ent situation. to provide special eiriergency treatment, if necessary-, and to indicate the role of the impairment in the causation --of the accicletnt,if there is g role.Accident information will be forwarded to the license administrative staff. Legislative arid judicial personnel - -Both the legislative and'judical.p son.nel who deal_ with handicapped driver, issues will be trained arid kept abreast of the state-of-the-art of the information arid research on special population drivers.The judical personnel will handle individual court ap- peals concerning DIvIlf administrative licensing decisions.The legislative bodies will enact the -legal frarneworlc. and funding necessary for this rite: -grated education and licensing system. to _function. Special population interest groups- -These 'are the groups of persons Epilepsy Foundation) particularly interested in the treatment and dispo tion of handicapped drivers:They will serve in helping to provide the- various special population-perspectives of the,syste.rn They will assist in supplying inputs as to the needs, liesires, and capabilities of the 1--iandi- .capped to both education and licensing agencies. They will also be useful in assisting handicapped individuals in optimizing their access to, arid interaction with, the education and licensing system.In addition, they- can perform research of specialized interest to further the state-of-the- art. Relatives --These are the relatives of the drivers who have =edical ditions.The y are to report to licensing officials those medically impaired relatives who, they feel, require special attention in licensing. They will be knowledgeable, as to their relative's driving restrictions so they may assist them in maintaining their desired level of mobility. General public --They will be ireforrried of the system so that those who become disabled will lencrw how to initiate the proper procedures in regard to the system.They will also be assured that au drivers who are liceris *d through. this system., rega.rdless of physical conditions, will be capable of driving safely. -17- Tiler es for entry Lnto this education and licensing sytterreCnie gr f handicapped persons to arned'how to drive when they were able-bodied, .mode -became disabled.These individuals are generally beyond the school-age and w the. rules and the basics of driving-The remaining two groups of potentialandicapped drivers never drove as able-bodied drivers.In the next group (andby .far the largest), there are -those vrlio were born disabled or, who be earrieclisaled prior to the legal-driving age and wan to drive at school- age. The third grop a drivers are those who were, or became,disabled prior to beginning drivingbut who are beyond school-age. The first groupf drivers already has knowledge and has developed skills relevant to driving,They may need to learn corit.pensatory sks (e. g. , they have become muscul-slceletally or neurologically impaired), and/or they may need to learn specifiprecautions (e. g. ,if they diabetes Mellitus ors car- cliovascular disease)The drivers in this -groiip already have valid. drivers' li- ases.The y enterhe education and licensing system by notification of floes.- ing officials that thehave conditions which might impair their driving abilities. The licensing officialare notified by the' handicapped drivers themselves, their private physicians, plice, emergency personnel, public health or hospital per- °rolel or their relati They are then required to be immediately re-examined for their license b DIE, or by specialized handicapped driver license evaluators.The applic ill be required to bring descriptive medical infoirnation from tr physicians public health depa.rtrnents with them to the re -exarnina-

evaluators assess the applicants.There are several possible de- this (a no changerin license status, (b) complete revocation of license(c) change to a restricted license, (d) referral to the driver improve- merit ar(Wyst, (e) refers.. to medical advisoryboard,(1) reqUire additional inedi- iriforrna.tion prior to nsing, or 1g) grant temporary license conditional upon eeipt of remedial driva r education by applicants withsubsequent demonstration of driving capability.If applicant feels that a change in the status_ of his licerise vas unfair or unjust, he request referral to the DIA or 1./fAB; or lae can appeal he courts.If an appli -ant been referred to the DIA or MAB, they will re- rnmend a license decis DMV. If an applicant needs- additionalinlorma- ticrr his medic l history and acquires this Lnformation, he returns to the DLE for re-evaluation ag Finally, if an applicant receives remedial training, he also returns to the IDLE for re-evaluation.. The next group of handicapped drivers are those who weresabled prior to the legal driving age and want to drive at school-age.'these drivers Have not developed basic drivers' skills and knoteledge, and do not have legal licensesprior

-18- to entering the system.They enter the sy terh in two ways. The first is thro education.Thdse who take driver education in school, private institutions, or private driving school will be ,pre-screened and assessed as to. driviag pcitential; and branched into appropriate programs.If theyiare accepted into valid educational programs, they can then be candidates for a learner's permit.. At this point, they enter the system from the licensing- end by applying to the DLE for learner's permits.If they meet the State' s criteria. for license eligibility, they are given learner's permits. Upon successful completion of the driver education program, they can - apply foe full licenses by going through the complete DTAr, evaluation. Then the process becomes identical to the first group's process wktb. some minor changes.First, their regular licenses are not dhariged since the full licenses have never -beea issued.Instead they are granted licenses or not granted licenses, and these call 'be either restricted or not.Second, they could not be granted temporary licenses, only extensions to the learner's permits conditional upon remedial education. The e ception to this cess is the individual who does e species. education from a school,r stitution or-private driver school. :be taught by his parents, relatives, or older friend.This driver would enter the system only at the licensing end. The third group cif drivers are those who have never driven, handicapped, and are over school age.These drivers enter the system in a manner similar to the group above, but they do not rely- upon driver education from the public school system.They are beginner drivers, and must start by learning all of the basics. All three groups of drivers will enter the educational and licensing system. This is, an integrated system with c onaManication between all members.It is me to allow full, adequate and specialized,trainiag of handicapped drivers, whether is a. complete driver education prograrn, or a small remedial training program. The system is designed to fully evaluate driver applicants for licenses, and to require in-person renewal as medical conditions change.Conditional liceases are alscr'an integrated part of the system. In the past, most driver licensing was c onside red in the biliary mode: the license applicant either received full license investiture or no license.Conditional licensing will permit the state to recogrkize the individual's need for mobility, while allowing it to, exercise its statutory charge to protect public safety by offering li-. censer which qualify driving with respect to the traffic environaneat,_ specialcluip..- ment, time, place, orthe r qualifications which the individual case may warrant. A very restricted license, for example, may only allow driving to work and for personal shopping through familiar neighborhood streets, during off-peak,hours, and daylight.The issuing of limited licenses allows some mobility- for rn.a.hy special

-19- who would otherwise have even greatermobility restricticins. Without thee r son almobility offered by a driver'sLicense, even- a determined row may loopforwwa -rd to a life of dependeecy andlimited personal grawth. Under the restricted licensescheme, a new driver with a,stable condition can gain experieece in a realistictraffic environment and may beable to earn a less, restricted license in time. lithe other hand, a drive;whose' ,ondition is not stale, 'andwho is becomi- by his conditioe, may requirefrequent license re-evaluationand ng alone affected license .renewals.The faster a driver's conditionchanges, the more frequent the renewal process must be.Since the evaluation of a. persoir'srisk potential occurs only at the time ofifcense evaluation, a changing condition/means achanging evalue The determination of tIrie frequencyof re-evaluation. and lic_en.serenewal will ation; This be treelLs op an individualvase(eoedition at the time of the fereviousevaluation. rnination of renewal frequencywill be made by the Dle8,l IA. i'vlAB or who- ever makes thelicensing decision in the individualciecurnstance.Most renewals will be in-person so thatobvious condition changes canbe noted, and so that appropriate tests, including road tests, canbe administered. wining will be required before,re-issuing It is quite possiblethat_ disabili- a licenseif a person's condi t do hasprogressed.If new drivi g related ties develop duringthe course of a chaeigingdisorder, new compensatory skills may be needed-beforethe license can be renewed.This reenedia.tionshould attempt point -wherec-onditiorl'k, or even full, licensing is feasi- to inc re'ase skill levels to a Akins (e. g. ble.Such training may .1.1)e aimed atteaching or retraining specifi& better visual search patternsfer certain.stroke victims; =safeoperating procedures for persons using specialatlapiive devices).Often,, all that will be requiredis, in- cautroys for the driver.For example, a diabetic maybe !s t ruction in special p re him liable warned toaintein a very specific diet sothat his condition will not make to a loss of consc_iousness .b .hincl the wheel. remedial lion I g system canonly offer such features as g ai.riti conditionalli i_ng if special populationdrivers are known, and signaled as such.Handicapped drivers can bedetected upon initial application for a license, and duringperiodic renewal of all delver licenses.They can be tee by self-reporting, by askingappropriate questions duringlicense appli- through reporting by relatives,and by DLE's observingobvious signs and yrnptorns. Fbr detection ofother handicapped drivers Islio areeither purposely avoiding detection, or who are unawarethat they have'poteetialdisabilities far driving, there are several avenuesof communication to the DMV. the physician Id report a patient whocould be an unsafe driver, both for the driver's safety andfor the safety of the generalpublic.In order mitigate the potential for jeopatd*zing,th traditionallir confidential patient= doetOr relationship, by the report, :thi legisla.ture will legally raquise physicians reporting un.der.guidelines established by the D.LAB.The MAB should coi5t of peers of the private physicians, and the MAD should be awareof the physician'd lifficulties.The reporting of a. handicapped driver does not result in immediate revocation of a driver's-license, e2ccept in especially severe case's.Instead, it calls for evaluation of the driver with -II-le potential for maintaining aftilllieense &nd/or remedial driver education and /ar a conditibnal license.. In the same vein, hospital and p-ublic health departriients should report pOten- tiaLly dangerous dri'vers.Police %rho, in the course of their riorrnal routine, spot drivers who are involved in accid,ents or violatipns possibly caused by disabilities Auld report such handicapped drivers to the DMV. There alsovrill be a requirez merit that the DMV establishes an. interface or hotline between itself and citizens who, in the interest. of public safety, alit to notify- the agency about a rela- -.:tive whose driving may be hazardous. To ,be totally effective, all corrupo.nents of the system hay open corn unication Links available to insure thatnthe special popa dij_ver is detected d reported, properly educated, evaluated, licensed (if possible), and reviewed periodically.This conununicationlvill permit records of the experiences of ,education and licensing to be kept and folic:Air-up data on the performance ofthese drivers to be sought as a'rnatter of due course.Specific research studies will be performed-to address particular problems.This information will be collected analyzed, and eva.luted to coratantly improve the performance of the,systern. I VIN G BEHA V PUtATIONS

In order o establish humperformance requirements for safe driving, more must be Learned aboutthe drivingtask.Even a cursory ekarnination of automobile 'dfiving reveals a wide range of variables (such as the vehicle, the highway- traffic environrnent and the human component) which combine to form a complex hwrian performance situation. These interactions, rnosnotably the not well understood cognitive and motor aspects of human behavi9r, have hindered the empirical study of driving. ..tinder the present';contraet, it was not feasible to develop a formal model.of driving behavior or to 'Conduct a comprehensive review of the work done in this areaHoviever," ix ordei; to evaluate the literature on psychomotor and, driving behavior .of "special popula.tiAns.,the project staff reviewed a number of articles and technical reports describing the drivingtask. We found that the experts in traffic safety'and human performance generally -agreed that, given the available information, human performance requirements for safe driving cannot presently be defined for either normal or handicapped persons.(Waller, 1975; Sipajlbt ,1975; Murghy; 1975; Huffman, -1975; Henderson and Burg, 1974; Less and Manus, 1973). A -enclerSon and Burg (1974) have pointed out, this cortainly cannot be considera. a cr'i'ticism of work that has beendone but rather an indication of-:the. complexity of the prob- lemAuider study.HoweVer, the :importance of the attempt is underseored,by the faCt that'poor human performance is considered by Many (but not all) in- vestigatore),,as causing the largest peicentage of autorTi bile accidents. Recently, Mcklaght, in work ponsoredby NHTSA, attempted to define and rank in criticality hiLman driving behaviars (Drivel Education. Task Analy- sis, HurriR11:0, 1971) in order to develop .driver'education training

A compiehensive analysis of the literature identified over. 1500 driver behaviors which were grouped into relevant drivel. tasks.These tasks were re- vie*edbY a- gyotipt of .qearly 100 traffic Safety experts in order~ to establish theiramPortane for subsequenttreatrn 'driver,edtication courses (Safe Pe rformance Curriculum, P re 7Vrive r ing Cours .,FrunaRRO," 1974). While there was a. critical need far. tiii. s 9, as a baboth'for future research and for driver eduCra'tion clarric elopme ,the study did not do- rnand a level of analysis which would, alio development of valid_.. huma:,, motor, sensory, and cognitive requirerrien or safe driving. tope. of defining these req ements, different hypotheses about the interaction of human s otGr processes have been investigated.rai attempt to define the visual requirementsconaporient far automobile ,Henderson. and Burs (1974) surveyed the literature on visionthought to be related to the driving task.. Using the Driver Eddcation TaskAnalysis (Mckaight, et 1971), they sySternatically eicaniinecl the 7Asual performance rameters which were judged to be irworta.nt toindivictial automobile driving taski. As a result a the literature reew, ten visual_functio.were identified , as being potentially useful for the developmentof vision.requirethents for licensing procedures.After an examination of the DriverEciucation Task Analysis, six (*), of the ten visual functionsremained as being relativelY. high in.importance to driver licensing: Static Acuat Perception of Angular Motion* Perception of Movefflent in Depth Dynamic Visual Acuity* Visual Field* Saccadic Fixations* Aare Sensitivity Fixations Steady Fixations_ Viso Henderson and Burg 1974) and Ellingstad. (1970) stated that it is generally reetignized that the driver receives most of the information he usesthrough his visual sense. Ata gross level the auditory senses are usually onlyconsidered important in the detection of warning devices (horns, bells, wind, or automobile system changes).In Henderson and Burg's review of the Driver Education Task Analysis (McKnight, et al, 1971), only oile itemWas found which had significant auditory requirements.This may have been more a result of the anal- Cal procedures used in the Driver Educatian Task Analysisfhan a valid ester:: lOn of hearing's relevance to safe automobiledriving.. Henderson and Burg's (1974) experimental work did point out, however, that the conditionsunder which ,,audito y stimuli are likely to be sensed by an individual with good hear nag (car at idle or low speed) are the same conditions under which a driver v.rith hearing loss will have greater oppcirtunity to use 'his other senses and thereby compensate for his loss, of hearing.In contrast the authOrs rioted that the 'interior and -exterior noise levels at higher speeds are likely to mask most auditory warning even _tar the now-hearing Tipairecl person. Based on their workthee authors felt that auditory requirements screening of, driver license applicants would not be. worthwhile.Little is known about the complementary interaction of auditory cs With other sensory cues in the driving task.In a more recent simulator std the deletion of a. velocity=-dependent audio cue (engine noise) did appear _tribute to the driver's inaccUracy..in maintaining an instructed vehicle speed this deletion was not statistically signiiicant (McLane and Wierwille, Two other' sensory channels potentially contribute to.the safe operation of the moior. vehicl..These are the vestibular and kinesthetic senses.These sources of information to the driver are often overlooked in the description of the driving task.Ellingstad (1970) noted that cues fturn these senses .are' im.- portant for controlling the autdrnobile both in acceleration and deceleration along the longitudinal axis of the vehicle as well as in transverse acceleration_ developed during cornering and skidding. He stated that, although not tested, it seems apparent in a skiAlLng situation that corrective response is initiated well before visual detection off the pivotal motion. McLane and Wi'erv.rille's (1975) simulator work does sugpst that these motion cues to the 'vestibular and kinesthetic senses" do Significantly influence driver performance. Since the information used by the driver comes from three sources (vehicle, highway-traffiC environment, and operator), driving behavior has been described as a dynamic situation where the Operator must actively search for and integrate iniormation. A numbs -i of human mental processing models (Gib- son, 1938; Learner, 1960; Schlesinger, 1967; Briggs, 1968) have been suggested to describe this process. ene rally, these models use visual input as their source of data along with four mental activities, namely: attention/search, per- -ception, decision making, and motor coordination. Many suggested measures -`for each of these specific abilities have been directly or indirectly studied in relation'to accepted criteria of good driving performance te. g., number of actual accidents or actual driver violations).Since ethically one cannot place human subjects in hazardous situations, the direct testing of these hypotheses has been methodologically- limited. However, much indirect hypothesis testing has been accomplished using laboratory psychomotor testing (e. g. ,simple and complex reaction tunes). While laboratory work allows food experimental control

-2 over the variables understudy, the diret applicability cgs to driving .is questioned.. The use of simuleSorsimproves the trans er rim ntal findings, but the reds always the question ofwhether there cient fidelity (e.g., feedback, environmental hard), inthe 'simulator task ow the development and acceptance (legal and social) ofhuman performance licensing standards. Epidemiological studiesalso have problems, since the results are always subject to theusu#.1 uncontrollable field study variables; not the least of these is the use ofdata tuned toadministrative rather than research needs. Acceptable epidemiological work requirescontrol for age, sex, exposure, drivingexperience; and often other variables. For the above reasons, much of the investigationinto human mental processes and driving has been donein the laboratory or on simulators. iZell, Rockwell and Mourant (1969), using eye movementrecording instfurnents, studied the search and scan fixa.tion patterns ofdrivers.They have demonstrated that all persons do not share the sameforward viewing strategy. New drivers demonstrate one kind of search pattern whileexperieneed drivers demonstrate another. The perceptual aspe"ct of driving (identification ofrelevant. cues and re.- lating these cues to pertinent stored information,Ellingstad, 1970) has been difficult to describe and to measure. Theautomobile - passing, task has been described as a perceptual judgment task.Jones and Heimstra (1964) found that dri-vers were likely to underestimate thetime required for one autornd- bile to pass another automobile. A similartoncept related to the human mental processes and driving is deciscon reaking orrisk taking.It, too, has been very difficult to isolate aid to testdirectly. Often'included in discussionof human mental processing and driving are- attitudinal studies.Attitudes about driving are thought to bepredictive of dri- ',ring performance (Harano, Peck, McBride,1975)., 1Fdr ha.adicapped persons, attitudes are often discussed as especially importantand predictive of corn- nsitory and safe driving performance. Many irreestigators have studied motorperformance,in these studies, steering-wheel reversals, speed changes, direction changes, andother'uni- variate (Greenshields and Platt, 1967) or multivariate(Ellingstad, 1969) output p'erforrna,nce measures axe used todiscriminate between novice and experienced driver(Ellingstad, Hagen, and Kimball, 197d) or between high accident and low accident drivers (Greenshields andPlatt, 1967).Recently; in a larg_e multiyariate study, Marano,Peck, ivicBilde (1975) found that simulator based performance measures (driver's braking,facceleiating, and steering) did not discriminate between high and low accident ratedrivers, Many human performance models reted to driving have been studied.` Fe rgenson (1971) found that high accidentrivers performed significantly more poorly on an information proceasin choice/reaction time testan did eithei low accident or high violation driveto. Similarly other investigators., (Brown and Poulton, 1961; Posner, 1966; and Helander,1975) have suggested that safe driving may be related to I.,.rivers' differingcapacities to pro-- ccss inform.ation.Helander's work on environmental-and humanpence_

complexity. capabilities may be able to 1,13o:tatecritical, high acdident situations se that basic work such as-Kellerman(human energy expenditure,1971) can be done.

As previously noted, the project review o the literature on the dri- g task and discussions with experts field revealed t.hat the driving task has riot been described in enough deta' en in ,the area of If4lli031,, which. has been closely scrutinized, there has not sufficient information available to es, tablish driver license screening requirements which could,app/y to either?normal or handicapped persons (although, current on-going kesearch sponsored brNHTS.As may. establish these requirements). However, the efforts of McKnight (1971), He- Lander (1975), and the new multi-disc iplihary accident investigations (Indiana UM- versity Multi-Disciplinary Accident File) will hopefully direct and epordinate fu- , tureefforta to define human performance requirements. .

B.The Re "e he Drivin Beha Literature for Handicapped Persons In this section, the following information will be presented for various handicapped groups: private and-commercial driving,behavior; driver education and assessment materials; present state laws regarding licensing; relevant medical opinion regarding examination and licen$ing; and any complicating factors which might relate to licensing"; suchas the use of therapeutic drugs.The terms used will be-those which were used by the original investigators or authors to elassifyiand describe groups of persons under study.The same practice will be followed for their statement of conclusions. surnmarizing the work, in the field, this document will cite all the experimental evidence pertain- ing to the driving performance of handicapped' persons as well as any stated, relevant anecdotal remarks.This would include, for example; the author's noting that educable mentally retarded drive EMR) appeared more easily flustered by a complicated driving environment than normal drivers. Warner (1970) offers a good review of many research criteria. involved in the study of traffic safety and accident research.Throughout this literature review, the project staff has been careful to' evaluate the experimental rigor of each study in light of these criteria.For laboratory work, this included un- biased samples, sufficient sample size, experimental design, proper analytical

-27- treatent, and' appropriateness of conclusions. For epidemiological studies, this usuallir meant control for variables such as age, sex, exposure (annual mileage and similarity of traffic-enviro1Aent); driving experience, anil socp- economic status. For reporting purposes, we have classified each study in ternis of experi- Mental riger into- four categories: case study, survey, and experimental studies (laboratory .&rid field) which were either "somewhat" or."well controlled.'; The case study is seLf-explanatory. A survey is defined as a descriptive study con- taining More than ten respondents and lacking direct comparison with a control group. A study which has some experirnent4rigor, for instance, 'control for sex and age but not exposure (annual mileage driver), would be classified as ''somewha controlled. " 'Studies with more than two relevant controls and no major design or analytical flaws (6.g., groUping a numbs r of different handicaps together) would be clasWied as "well controlled"stildies.Although minor deviations may be noted in classifying a particular study,' the language used will conform to the definitions presented in this 'paragraph. Theyre are many examples in the literature where experts in the field report their experience and recommendations without data.This includes the recommendations kf state medical advisory boards and special conferences. When these experiences or recommendations are reported, we will endeavor to document the source of the opinion as well as the qualifications of the experts. E Undifferentiated Handicaps

There is a large amount of pntradictory- opinion about t1 t1 driving performance of handicapped persons. ,of5the reasons, as West (1963) noted, was the tendency of many researchers to assume that the physical impairments of drivers were irdPor%tant in the causation of accidents. Some observers (West, 1963 ;`'sander, 1976) felt, however, that very Little go ©d evidence had been colleatecl 'either to confirm or to deny such an assumption. Much of the early research did not control for age, sex, experience, or exposure, and often used heteroieneous rather than homogeneous experimental groups-.Valid compa.ri- sons, therefore; were nearly impossible to make.Often the only evidence pre- s-ented were case reports of- "safe and successful" or "dangerous" handicapped drivers (McKee, 1954; Altobelli, 1964; Schwelkert, 1969) The reports of general surveys (Finesilver, 1970; Connticut Depart-. went of Motor Vehicles, 1970; New South Wales Department of Motor Vehicles, 1971)' or state licensing screening programs (Wilbar, 1965; British Medical Journal, 1966) were not much better".Pinesilver surveyed over 400 safety pro- fessionals, licensing officials, and judges.He reported that 71% rated handi - capped- drivers as average or better than the general public with, no one having as hazardous drivers.The Connecticut DMV loolced at the approximately 4,000 of the State's licensed handicappeddrive reported that none had been guilty. of serious or dangerousviolations and One had any traffic problems as a result of his orher phYsical handicap. ame-lcind of evidence, the New South Wales .D.MV reportedthat phy.- aps of= one type or another had not been found to be related toacci- dent rite. Moreover, Wilbar (1964 and 1965), reporting op,the voluntary driver ;tic g screenifig program of Pennsylvania,stated that .04% of those 16 yeare oJf age and 0.7% of thosev,61-93 yearsof age failed their 'physical examination. LIn.ilarly the British Medical Journal, citing information from West Germany and Sweden, reported road traffic accidents due tochronic dia0Eders f O. 6% and 0. 8 %, respectively. Even in somewhat more controlled studies, differentiationbetween ndi s with differingfusictional disabilities was, not always reported, erner and Yew-14er (1962) compared the accident experience of 120 driverswith "pro- gressively chronic digease conditions" to that /of a randomly chosen control grcup (matched for -age, sex,license-holding period, and exposure).They found differences.Buttiglieri, Guennette-, and Thomson (1969), in a. somewhat controlled investigation, ,grouped 798 medical-surgical patientsand foluid, with respect to accident experience, that they did not differsignificanay from eitherrandom sample of male California drivers or a selected group of psy- chi.atri.pdtienta.With respect to `violations, both patient groups had significantly higher violation rates.Baker and Spitz (1970), using autopsy evidence, found no correlation between driver accident responsibility andevidence of disease or physical disability. bx terrps of education for the "handicapped" there is a similar problem. Many authors simply reported that handicapped studentsreouir4 more instructional irne, (Qutsliall, 1962), that they fatigued more easily (Garris,1973), or that they required more"ositive re-enforcement than normal driver educationstudents (Stiska,1972).There was little spec4ic information on theeducational needs of persons with particular handicapping conditions. :ost programs can ?nly recommend general educationalguidelinesor. the Ila.nda apped_ learners : Beware of reading deficiencieg and gearliandicapped driver e u- cation mate rials to low reading.levels 1974; Misner, 1975). Modify normal teaching techniques: to develop progr nth high repetition (Mullin, 1974 Be sensitive to the motivational and emotional problems of at+ dents since even minor failure c evelop into a major emotional pr.oblem (Otiska, 1972; Nemarich and Vallerva'n, 1964). Use a simulator in order to gain a city with automobile controls before "behind-the-wheelinstruction (11efisner, 1975; .Bartels, 1975; Mullin., -1974). Use a special education instructor or a driver education instructor who is experienced in working with the handicapped (Bolinger, 1970; Reynolds, 1975). Shorten nbrrnal instructional time to a- maximum of 20 rninu (especially on-the-road instruction) (Fisher, 1975). A few programs ffered separate tracks into which they-placed persons with erent degrees of drsabr ty.Bolinger (1970) deScribed four tracks: Track A: Students Obtain learner's permit on their own; behind the wheel instruction is done by traditional drives education instructor. Track B: Traditional driver education program with only portive assistance from special education teachers. Track C: _Use of special education instructor with the traditional driver education teacher in a supportive role. . Track D: Additional or supplemental assistance is given dr be hind the wheel instruction.

. Most program used individualized instruction and simply adapted cu ro normal driver education materials as required. Individual programs were likely to have assessment or driver education. screening procedures which were unique to .their staff.These ranged from very informal (response to verbal questioning, noting ocularcontr& of fixation-time during an interview--Fisher, 1975) to the exteriiiive use of formal diagnostic,. tests WAIS, WISC, Bender Gestalt, Siebricht Attitude Scale, Raven Progres- sive Matrices)./s/fore sophisticated testing was dependent upoireither the availa- bility of professional assistance (psychologist) or, the experience and discretion of the driver,education personnel.In some programs; this assessment was done

-5 suriulato rs(1..dong, 3974; . Brown,19-75) Later, the d riving r ucto d beh..ind-thewheeia-astiuc tion, must make another it-I.-car asses t.This may be the noting of "pe rcepttial" deficit s car emotional p roblerns behit d the wheel (Sipajlo, 1975). ctu- Hi ste ri onl y,the l ni orarilehicle Code has had gerie,,ral provi which state that a state departznent of 2-notor vehicle s sha,41 not y dii ver Is ense -to,nor r en,ew t1-2.e driver 's license of, any ppersom: Vlho has previ ously- be en ad judged to be alai cted with or suffering fro= any ni.en.tal. disability Or disease and who las not at the time of a.pplication been restored to competenc y byl e methods pro- \Acted by law.

lArlien --the .commissioner has good believe that such per- oon real on of physi-cal vvould not. be able t o ope rate a. motor Nel-r.i.cLe with safety upon the highw All but ten sta tes have c mparable ats tutoary prosiona for -both eral pxovision,s. The validity of tIe se ,statutes pe rmitting the denial, suspension, re - vocation of cancellatf_on of a driver='s license dor physical disability does riot appear to have ever been seriously qustioned,tt is generally the ugl-it to be justified tinder state statutes empowering licensin_g a.drninistxaters to malce p ons d.esi_gned tolirrit the operation of motor vehicles to tiose who are c orrApe-ten_t to do so (,Ari-iericai raceSecond Series) .More recent court cases may s uggest tlat a stte may be re cluiTed to justify its l ceaisure prouedzirs in order to insure s pe cial populations' eqqat rights under the law.

e ntal retarciati on has open described in a yari S from do- g roes ofrriyai rrn.errt ira a ctit .es of daily liv-ing ing of yenta and 121-Lysica_la-npair-rnent, 1 964) to deg _Tees of izttllecti..aafunctioning based on IQ (Corm-nit-tee or Nern_enclature and Statistics of the Arilcan Psychiatric As So- ciat5on, L96 8;U. W. ,1 (368,). Its causes are unk_mown but can range from genetic defects to tratunatic injury.In_ driver ye rfo rrn_ance research, many, terms are used to describe thi s c onditi onrtiental retaxda-tion, mental eerie ezacy_ , educable mentally rota rcled (ENR), educable merit:2,11y hanclic apped (Eiviii) becility, low intelligerl ce, etc. Ocas sionally, psyc hi:I-trio-tor deficits are de scribed.

-3 1- as being related to intelligence(Banks, 1974; Dawson, 1967; Phillips, 1967; Wagner and Schaff, 1968),The research and opinion described in this section contains a composite of many difie rent perspectives anddefinitions of this hartcap, It has been William and Littl (1966) experience that the mentally student can be taught to drive..Kesterson (1975) said that IQ level_ at predictive of a person's ability to drive.In agreement Wanner (1974) stated that it was not the ind1vidual' s mental capacity but how he used is abilities and how he was taught which determined his ability to drive. Ad- serba.11e (1974) and Latimer (1975) concurred but both felt that the lower the IQ, the lower the chances of learning to drive safely.Sohn.son (1975), as a rule-of- thuneb, suggested that students with an 10 below 60 will have little success in learning -t© drive ; lit -he sleted that tine rule is somewhat dependent on which of the IQ measures is low. Arne rican Medical Association suggested another rule-of-thumb. A person who was menially retarded and who cannot learn to ad was likely- to have difficulty learning to drive safely. Long (1974) reported that the mentally retardedindividuals were assessed as to driving potential on a driving simulator.VA three passed and were referred to a drivingschobl.In West Germany, Slugs. (1968) questioned 33 people with driver's licenses who were mentally retarded.Be found that the handicap appeared unrelated to automobile accidents causation.In Swe- den, 43 mentally retarded persons were issued tractor licenses and Z7 were issued licenses to drive a car over the years 1966-1970 (5eskow, 1973).Most had IQ's between 60 and 80.As of 1971, three had auto accidentsL.nd two had tractor accidents.Only ten still drove cars, while 18 still drove tractors.Of 15 persons mentally deficient who were denied licenses but still, drove tractors,. seven had accidents.Their IQ's ranged from 60 to 30.In 1955, Canty reviewed 81Z cases of problem drivers.He fourel 30% were mentally retarded.liampel (196Z), in a survey of over 1,000 people, came to the conclusion thatthere was a relationship between IQ and safe driving.Of those people who caused accidents the mean IQ was 91.People who had frequent traffic viola.tions.buttilid not cause an accident had a mean IQ of86.Those who failed the driving test more than once had a lower than normal IQ; Harepel pointed outthat the driving. test was a measure of driving ability.

In a. sorrietivhat cozmtroll ted y,( torte of Illinois, 1974) 35 EMH students' drivieng records were reviewed .enva five year period (1968-1973).These drivers were in 41'% more accidents than the average forall other drivers in Illinois.However, in a follow-up study frOrTi November 1973 to November 1974, these 35 drivers were involved in_ no collisions.Gutshall' s fairly well controlled y (1968) concludedthat a group of drivers with lower intelligence (mean IQ ad a- higher number of combined accidentsand convicted traffic violations than average IQ drivers, butthe difference was riot statistically significant.The low IQ groups had more points for violations(other than spec gl than either the average or above average IQ groups.Self- reported mileage driven per year also indicatedthat the low intelligence groups did spend more time in their cars. sight Fels/Mrs meeting intelligence and performancecriteria (percep- ti n and reaction time) in a. drivereducation program were compared witheight students who were intellectually normal.(Pa.ppardlcov and Bowan, 1960).The OMR' sr had mean. IQ's of 70 ori the verbal(WA L5) and 80 on the performance (WA The normal group had generally superior vision,distance judgment, and glare recovery.The groups were equivalent in color vision.The EM13.1s had slightly better reaction time.All of the low intelligence group passed the written driver examination. Two passedthe road test on the first attempt; two passed on the second attempt; one passed onthe third; and, three never passed. In a more recent study, Egan (1967) compared18 FMR and 18 randomly selected regule r students over a four-yearperiod. The ages ranged from 16 to 19 with IQ' sranging from 47 to 75. He found that regular students had superior distance judgment (distance betweenautomobiles), better complex reaction time and steadiness, andbetter knowledge of traffic laws and regulations.Both groups were equivalent on field of vision,color vision, visual acuity, and night vision.With considerable coaching the EMR' s passed the drive r license test. The lowerintelligence group had difficulty with speed control, often because they failed towatch the speedometer.. They also had diffeculty in making quick and accurate appraisalsof approaching obstacles so they could rake compensating adjustmentsin their driving.The EMR's group, by comparison, had twice thenumber of accidents. Egan's conclusion wasthat the EMR operate s an autornobi*, at amarginal level.

Bologa,et al. ,(1971) compared 3491/113..'s with 443 normal (N) high school students.All had valid driver's licenses.The ages ranged from 16 ,o ZO and the two groups were notmatched. The following conclusions were reached: There was no difference between the groupsfor speed, steering, signaling, or bra -king on a simulator and norelationship to'accidents and violation. EMR' s reacted slower than ti e is to a majority gency situations involvingbraking and steering. The EMI.' s an ve rage of one year longer than t: There was o relationship betty driven per year accidents and vioLations for Elsat' s. Fewer MAR.' 5 had driver education tb..n normals. For the EMR there we're fewer accidents and violations when they had driver education. Even though there was a diffe eritally re tarded group and the norrnal stu nality que aim - naire, the ie vas'no relationship 1:ye the questionnaire and accident and violation rates. In general, both groups, the better the visua acuity the more likely they to be involved in accidents and violations. For the EINAR' s only, the more accurate they were in perceiving situations close to them (ability to judge distance), the less likely they woUld,beeorne involved in accidents and violations. There was elationship to accidents or violations and color vision for either g rot p. The re was gative relationship b koad scores on visual attention, depth -Asuali2ation, re ognition of complex detail, total number of tests passed, and percentage of coreceva,riables of the Wilson Test of Driver SelectinT1 and low accident and viola tion rate's. s who did well on the recognition of simple detail aril eye- hand coordina.tion on the Wilson Test were less likely to be involved in accidents and violations.

All high s for eWas c n Sub- is were related to low accidents- an atioris for normals. Ransford (197Z) feltthat there may be problems in licensing riser -' tally deficient individuals to drive a oar. Adserballe (1974) was of a different opinion.hi a Danish article he stated that if they are able to pass the driver test then they should be able to drive. The Industrial Medical Association(1966) suggested that each commercial organization should establish its own criteria for he level of intelligence ded.It recommended, however, that a corn rnercial driver be able to re (rand write and to interpret signs.He shoidd be at least a grammar school graduate and high school would be preferable: The Ynedical guidelines for East Germany (Koschlig, 1974),eco mended that people Who exhibit severe or fairly sere re. mental deficiencies should riot drive. or mentally retarded who have a less severe hanelic per- rni sion can be given to drive commercially and privately if outstanding social a,djustrrient, responsibility, and ability to function in society can be-proven. The Nio-va Scotia Guide for Physicians (Nova Scotia Medical Societ9., 1965) stated that people with an IQ below 80 are not fit to operate a moicir The A rrie ricari Medical Association disagreed with this. recommended that drivers with IQ's below 70 may not be able to make acct. -ate decisions under rne rgency situations and they, therefore, should bekept from heavy traffic or stressful conditions and not be allowed to drive commercial vehi- The Canadian Medical Association (1974) was in general agreement but not specify an IQ level. The Quebec .Ministry of Transport (1973) re quireci a driver to have an IQ of at least 70.If his IQ was =between 70 and 80, he 'rna..y only drive a private vehicle.Beskow (1973) and Wallner (1974) reported that Swedish law has removed IQ limits (used to lie an IQ of 65).Now each individual has to be evaluated as to his emotional maturity, common sense, social adaption, technical ability and motivation. The Uniform Vehicle Code states that a. person will not be issued a license o r have one renewed if'.(a) he is suffering from a rnen.tal disability: and has not bcefi restored to competency, or (b) if the commissioner has good reason to believe that a person, because of his mental disability, would not be able to operate a motor, vehicle safely on the highways.Forty-one states have simile r c ode s'.For the legal ofession, Words and Phases (1965) defines an "incompetent person" as an individual who is so mentally impaired that he is incapable of driving a motc--/t-

:Nlentally retarded Jdes are screened in va sou- .N.vays for entrance a driver education program.Bloomer (1975) repirterthat he r students below 75) were evaluated by a teacher, by a battery- of psychological tests as as`-by a guici.ance counselor prior to acceptance into a driver education program.Tohilson (1975) reported that students who can successfully ride bicy- cles, who have a high leVel of independence and who have the support of their parents and peers, generally are the best candi'dates for driver education. Ac- cording to Mullin (1971), and Bologa,et al. (1971), pupils should be screened by teachers, school health services (school doctors and nurses), guidance counselors, and school psychOlogists.Pappanikow arid Bowan (1959) have five criteria for entrance into their prog ram:(1) IQ of at least 70 on the performance

-35-

fi sub-tests and 6Q on the verbal sub-. Wechsler., (2) no lower than 4.0 grade level on the CaliforniaA .TQst,(3) be at least 16 eyears 61 age, () be medically fit, and(5)` feet pas g score on perception and reaction-time tests. Dick (1971) reported that0rhato tl re+e-quart rof the EMI can succeed in a regulardriver eriueatibn program, but theylustrepeat course tvo or threetines.- Little (1966),Nvith special classes, estimated that it Cakes three to five tirles longerto teach ENE.' S than it does to teach normal students.Bloomer (1975) 'reported that each oilier studentsspends a total of .30 hours driving on the road (her studentsall were below a 75 10).This is broken down into 30 minutes of obs.eryation and30 minutes of driving, as well as 30 niinute s of class room learningdaily.Pappanikow .and Bowan (19 gave their students a total of 80hours of classroom instruction alpng,with. 18 hours behind1-te, wl de1.Only 30-60 classroom hours, along with-10 -60hoots of.in-ea,r instruction, were usectin the programrepOrtedy Oeollericin arid Lati- mer (1972). One as ect of driver education 10 mentally retardeedretarded is theuse of nnulation."lt is used quite frequently a.rtmany, find it useful. (Oellerichand Latimer, 1972 and Johnson, 1975),IVlc1-31-ie roon and Kenel (1968), in an experimental study found that EMII's (IQ 55-77, rrteanof 66) perceptual abilities improved with simulation instruction,They also found that the higher the IQ '(they also studied average and above average 10students) the greater the improvement in perceptual ability through siiltulation. ,Bo'iinger (1970) described a four-track program that can be used for teaching s:(1) students obtain learner's permit ontheir own, behind the wheel training is performed by a traditionaldriver education teacher;. (Z)traditional driver education program with only supportiveassistance from special education teacher; (3) use of special education instructor with thetraditional driver education teacher in a supportive role;(4) additional or supplemental assistance given, for behind-the-wheelinstruction. In a symposium ©n_clriver education cl the EMR (Dick, concluded that a pre-driver education course should beoffered for ore they begin the regular driver'edue,ation course.This pre-driver ecluea- n course should be presentedby the special education teacher.While the regular driver course is being taught, the specialteacher would stop teaching driver education so that the EMR's do riot becomeconfused.The special teacher could, however, -provide reinforcernenit to the ErvIRwhile the regular course is progressing. For the most part, regular driver education coursematerials can be rewritten for the mentally retarded students' reading level, e r son and' O'Leary' (1969) mentioned that there are a number of techniques a. special education teacher can use in teaching driver educaticin: concept 'reinforcement,- observation and re- teaching; team teaching, teaching solely by the regular driver educatioin nstructor, and driver education taught solely by the special educations instructor.Having an instructor with certifica- tion in both driver education and in special education can be an advantage. Oelletich and La une(1972) described three different courses for' dri ver education for-ErvIR's:(1)' a basic course in driver education; (2) an advanced course of driver cducon; and (-3) a course concerned with pedestrian and vehicle passenger safety. ullin (1974-) and Bologa,et al., (1971) cescribed a curriculum as follows: 9th grade screning of st ,teaching basic vocabulary related to driving2 reading titans and procedures of driving 10th grade

classroom theory .ng h grade practice drivi la or, d riving range and,street'

1 nth grade refresher courft,

McCune 970) fell that state traffic laws, traffic signs and symbbls, reading questions on a driver examinatio.n, responding to verbal or written questions about driving, driving a car, and applying traffic laws were topics that needed to be taught to mentally retarded in a driver education course.Curriculum materials for teaching driver education to EMR's were available (Michigan Department of Education, 1968; Latimer, 1975, Gracewoocl State School and Hospital; and State of Florida, for example). Stiska (197. ) emplaasize6 thernportance of positive reinforcement schedules which will aid the studonin learning the materials.He also Stig-

, gested that lessons should not last more than 20-30 minutes since EMR's, have limited attention.McCune (1970) made the point that the mentally deficient have difficulty learning couple c materials in a incidental mariner, while state driver examinations measure only minimal knowledge on the assumption that drivers will acquire additional knowledge incidentally,Therefore, acquiring and applying the more subtle aspects of the traffic laws,requires a relatively structured driven-education program.Mullin (1974) recommended that special driver education instructors should be sensitive to individual reading deficiencies, provide reading material at the appropriate level, and build in a large a.mourit Ot° repetition.Fcrr driving practice he stated that manipulative and pereeptual skills, should be developed first.One method for the development of manipulative skills has the student wearing a blindfold while practicing the use of the controls.The EMB.' s need much practice, and the key points of driving need to be emphasized. McPherson and O'Leary (1969) pointed out the problem of poor transfer of learning from the classroom to the real driving situation.They suggested that whenever possible, classroom and on the road training should he integrated and taught concurrently. a,timer- (19,75) ntionefl that even if the EMR's are not given driver licenses after they have pieta(' driver education, it is important for them to understand traffic frorr safety point of view.Pappanikcfew and Bowan (1959), stated this in the goals driver education program: establish respect for hazards of autornobile,hotly as an eptfrator and as a pedestrian; develop good traffic attitudes of theotential driver; increase a general interest-in school; and develop safety aeets for both drivers and pedestrians. Nlental Illne There are ri of mental illnesses ranging from personality disorc through psychosesand-- neuroses, to psychophy-siologic disorders (A me rican Psychiatricil.Eio(dation,. 1968).Obviously they are too numerous to describe this report.-The readetnof this report is cautioned that diagnosis of mental illness isfficult and sometimesunriliable.In addition, although the nomenclatureused in one study being reported may be the same as in another study, no assurance that t-wo studies by different people at different times use diagnostic, c rite ria. Ransfo d (197Z),sporting in C,a_.nada on Medical Factors in Traffic Accide=nts, stated thatthere no good information on psycVatrie'problerns. While there is not a large unt of definitive information, t ere are some research snitches on driving rforrnance, on the therapeutic drugs associated with mental illness, and on'uidelines foh licensing.One study even discussed the psycho-sexual aspectst people who were responsible for traffic accidents (Schuman, 19729.

-38- Sluga (1968) stated that psychopaths andneurotics are dangercu dri-' vers and have highaccident rates.Canty (1955), in a review of over800 cases of problem drivers,reported that 51.2% had mental disorders (psychotic: 2. 0%, psychoneurosis; Z. 7(%, personalitypa,ttern disturbances: 12,7%, personality trait disturbances: 32.2%, sociopathic personality: 1.6%).However, the effect of mental illness on drivi g abilityand the role it plays in the cause tion. of traffic accidents is difficult evaluate (Berger, 1975).Berger cited two cases of paranoid schizophrenia, two casesof neuroses and a personality disorder in which the illness -was the causeof their traffic accidents.Writing in the South African Medical Journal,Cheetham (1974), felt that the following types were likely to beinvolved in traffic accidents: psyChopathic people who are impulsive, aggressive andlae ing in conscience who use the automobile as a weapon orexhibitially; hypomanic people who are described aS beingimpulsive, aggressive, lacking in judgment, without thought and carefor ethers, and =able to tolerate frustrations; and psychotics and near psychotics who lackjudgment and insight and frequently are out of touch -with reality. In contrast to these opinions, Ian Hector(Kenyon, 1970 ) believed that axjor psychotic illness contributes very little 'to accidents...

Ln the New Zealand Medical Journal,three caseS' were cited where persons who were diagnosed aspsychopathological were involved in automobile accidents which appeared to be suicides(Grimrnond, 1974).MacDonald (1964) also presented cases wheresuicide and homicide are associated with automobile driving.He concluded that both wicide andhomicide are attempted more frequently with automobiles than is generallyrecognized.Thirty-three psychiatric patients previously diagnosed assuicidal were compared with 2.7 other psychiatric patients (Selzer attid Payne,1962).The suicidal patients had more than twice the number of traffic accidents per personthan the others.in a somewhat controlled study, 96 surviving anddeceased drivers responsible for fatal accidents were compared to a like niLmberof controls (Selzer, 1969). The drivers involved irl:cfatalities exhibitedsignificantly more psychopathology (41% vs. 17%) and social stress (5e% vs.18%) than the controls.In a' sociological investigation Porterfield (1960) concurred sincehe found positive relationship between rates of death from motor vehicleaccidents and-suicide and homicide in the 60 largest metropolitan areas inthe United States.

-39- However, the driving records of165 patients admitted to euro- psychiatrie ward were analyzed forthe three-year period prior toeir ad- mittance (Buttiglieriand Guennette, 1967).Their accident and viiolatAon rates were not significantlydifferent from that of a randomlyselected Sample of normal drivers with the same mean age.In another article in1967, Butti- glieri and Guannette (in Pe ree tualand Motor Skills) compared the driving performance of 361 male neuropsychia.tricpatients to all male California drivers. Over the three-year period...prior tohospitalization, the patients had similar accident and violation rates whencompared-to the other drivers.However, the frequency of accidents andviolations for the sic month periodpreceding ho4italization was higher than would have beenexpected.

Eelkenea. et 1.(1970)studied the driving records of 23iatients discharged in 1960 from a mentalhospital and compared them with a eetiktrol group of normals matched for age, sexand county of residence.The follo,king results were ,obtained:(1) psychotic and psychoneuroticshad a higher accident rate than controls before 1960, but weresafer than controls after discharge',(Z) people with personality disorders had thehighest accident rate before1960 and tended to show only minimumimprovement after discharge; (3)hospital diech4gees have a higher accident and violationrate per hundred driver yearsthan controls; (4) male psychotics andpsychoneuroticS increased their viOlaCionrate after discharge compared topre-1960 performance, and they had ahigher rate than controls; (5) female psychoticsimproved their violation rate after discharge: (6) there is a significantdifference in suicide attempts betweenpatients with eingle car accidents and thosewith no accidents; and (7) there is norelationship between homicide threats,attempts and successes anddriving accidents. One hundred thirty -five patientshospitalized for sto,x&aeh o duodenal ulcers were compared with theOntario male driving population (Smartand *Schen-lit, 1962).The ulcer patients had had significantly moreaccidents per person than the companion group,.Selzer et al. (1968) compared,96drivers causing fatal vehicle accidents(F drivers) with 96 drivqrsrna-tched,fer age, sex and home county.The F drivers had more psychopathology'than the con- trolsmore paranoid ideation, suicidalproclivity and clinical depression. They also showed a higher level ofsocial stressmore personal conflictand vocational-financial stress.Twenty percent of the F drivers alsohad acutely disturbing experiences (usually quarrels)within six hours prior to the fatality. -In a study (Washington, D. C.DMV, 1973) of medically impaireddrivers, the poorest drive rs we re those considered mentally ill- - .anxiety neurosis,depression neurosis and sChieophrenia.Waller (1965) found that in an ageadjusted comparison between 194 mentallyill drivers and a control groupof 9, 2 Cali- fornia drivers, the mentally illdrivers had more than twice thenumber. of accidents expected and 1.8 timesthe number of violations.

-40- Perrine (1974) reported, after a w of the literature erapeutic drugs and driving that, to date; there no determined effort associate the use of psychoactive drugs by drivers specific driving errors with responsibility for accidents.While. this nerally true, there arefew studies and' opinion's on the effects of some drugs used for therapeutic reasonor the mentally ill.The next few paragraphs desoribe this literature, specially discussing tranquilizers, sedatives and antidepressants. Ataractics (or tranquilizers) can be divided into seven categories (Physician's Desk Reference, 1975).The driving performance literature dealt with only four of the seven: phenothiazines and cornbinatiRns, meprob rnate and combinations, butyrophenones and combinations, and oche, types,Keilholz and Ilobi (1974) stated that tranquilizers a.re of interest to traffic medicine since they produce fatigue, are muscle-relaxing and their effect is increased by alcohol.Cheethamn (1974), in a South African journal, reported that high doses of tranquilizers may cause a person to be euphoric, exhibit a "don't care" attitude, possibly become sleepy, or suffer from a sudden attack of low blood,pressure with subsequent anoxia and loss of critical faculties.Waller (1972) stated that there was anecdotal evidenCe indicating that some individuals are involved in roadway accidents because of the effects of tra,np,41izers. There were several articles that da cussed the ataractic phenothiazine. Perry and Morgenstern (1966) stated that people who take phenothiazine type tranquilizers may have trouble driving.Patients who were on phenothiazine performed the poorest in reaction time tasks thought to be related to driving (Sav- age and Wilkinson, 1971).In 1963 Brandaleorte suggested that chlorpromazine could produce drOwsiness which' could affect driving in some patients.It was Wenckstern's (1964) opinion that doses of more than 75 mg. of chlorpromazine shoUld preclude driving, and that 50 mg, influences driving ability.This same drug, with`a delayed onset, impaired performance on a simulated driving task (Loomis and West, 1958 as seen in Nichols, 1971).While Weatherall (1959)- found that prochlorperazine taken at 10 mg, twice a day had no effect on simulator performance, he noted that 50 mg. of chloi-prornazine did impair performance on a driving simulator.Miller (1962) found_that after one week of-20 mg. per day, subjects exhibited-poorer performance on simulator driving tasks.Trifluoperazine has also been found to have 'significa.n.t negative effect on the driving performance during three, low speed, vehicle handling tests. (Betts et al., 1972).Linnoila ,(1973) found that thioridazine negatively affeicted attention skills related td driving but did not affect coordination, Brandaleone (1963) stated that the tranquilizers of theepizobamate type may affect driving in some patients,According to Wencksrn (1964), 400 - 600 mg. of meprobamate can lead to decreased driving ability,.They can cause

-41- euphoria some patients.Smith et al. (1958, as dizziness, sleepiness or performance seen in Nichols,1971) found indications ofimproved simulator among, some groups ofsubjects after administrationof benactizime hydrochlo- ride (a meprobamate).Other simulator studieshave, shown no change, in performance after takingmeprobamate: 'Miller andUhr's (1960) study (as seen (Weathera11 --1959); and subjects in Nichols, 1971);subjects taking 400 mg. taking 800 mg. and 1600 mg. perday (Miller, 1962). Miller(1962) reported slowed reaction timeswith 1Z a. nxidus neurotics,but he also reported decreased anxiety and tension. Haloperidole (a butyropheno.ne)reportedly affected the attention of driving but did not affectcoordination (Linnolia't subjects on tasks related to did not-affect performance 1973).Betts et al.(1972)reported thathaloperido19 on three lowspeed vehicle handlingtasks. been studied.Diazeparn'(Vallium) did not Other ataractics have also administered the pre: affect psychomotor skillsrelated to driving when it was 1973).Diazepam in doses of 5 and10 mg. did not af- vious evening (Linnoila, (Linnoila fect those psychomotortasks when taken just priorto performing them and Mattlia, 1973).Linnoila (1973) stated thatdiazepam andcl.Llordiazepoxide alone in therapeutic dosesdid not impa'r psychomotorskills related to driving. 1-10V/ever, Betts et al. (1972)found t chlordiazepoxide did affectperform on three low speedvehicle handling tes}

. barbi- Sedatives can be drdya d intoi twoclasses: barbiturates and non- and, kIajai (1974) ;. andDokert (1970) wri- turates.Brandaleone (1963),, Keiiholz respectively, agreed ting in the United States,Switzerland and East Germany, that sedative's (and hypnotics) mayproduce drowsiness. andtiredness and that these drugs may affectdriving,Waller (1972) stated thatanecdotal evidence showed that some peoplehave traffic problems whenthey take barbiturates. Wancksterp (1964) reportedthat -barbiturates. affect the ability to react and to concentrate and remainin the body a long time(over. 12 hours): An acute dose 100 rr g.)of quinalbarbital producedmuscle impair- Weatherall ment in performance on adriving simulator (Weatherall,1959). also reported that ashort acting barbiturate,arnobarbital, at doses of 100 mg. Betts (1972) also showsdecrement in performance(in impaired performance. amobarbital. three low speed drivingtests) of people while underthe influence of After six days of 30 mg. ofphenobarbital three times a day,Miller (1962) de- rnonstrated some lowerreaction time measures on asimulator.Loomis and West (1958, as ,seen inNichols, 1971) reporteddecreased performance on a simulated driving task due tosecoba.rbital.Secobarbital showed\a negative effect on other psychomotortasks related to drivingfour hours after administration and eight hourslater--wiph sleep intervening. -barbiturate sedatives may also have an effect on driving peor- a.n e. e rry-(1966) cautioned that driving under theinfluence of Chioralhy- drato, pa aldehyde, glutethirnide, and ethchlorvynol maybe hazardous. Wenck- stern. (1964) reported that rauwolfia alkaloids diminsh reactiontimes and,' perhaps, decrease blood pressure which could lead to syncope:in another study, eight hours after administration of flurazepam there was a generaldecrement Tin psychomotor performance related to driving (Bixler et al. ,1973).Unnoila (1973) fownd, that middle-aged subjects showed impaired performance inthe morning after taking nitrazeparn the evening before. He alsofound that ethin,a- mate slightly improved co-ordinative skills but impaired attention(on task9 related, toeriving) the following morning. kert (1970) reported that people who are takingantidepressts have questionable driving ability.The effect of antidepressants on driving abiUty has net heeri investigated much (Keilholz. andHobi; 1974).The effect of the different medications differs considerably and can bedivided into these chief cate-

go rie z the ightening of one's mood--"up", increase of the urge toaction and the suppres ion of anxieties.The chief danger is their potential sleep-inducing effect at the beginning of the treatment.The recommendation is that the ambu- latory patient be started with small dosages. and that the doctorrecommend "no driving" at the beginning of thetreatment. There are differences concerning the licensing of the mentally turbed. whether they are taking medication or not.The Industrial Medical Assocl (1966) recommended that employees with psychoses or psycho- 'neuroseshould be evaluated on an individual, basis as to whetherthey should be alloweto .drive commercially or not.Any medication taken Must alsO be cdnside rod in its effect upon driving`.The 13vIA also cautioned about patients discha xged from hospitals before they are completely w mentally. 4 rballe (1974) reported in Denmark that the driverapplicant mental fiteass is judged by the police.They made their judgment based upon a health certificate andother available sources of information.Only those with serious mental disturbances had theircondition thoroughly examined prior to receiving a drive r! ,s license by themedical examiner, the motor vehicle ix.$pector, or the department of health. Guidelines for medical advisory boards (U.S. DaEW, 1969)made ocommendations. They felt that most serious cases ofixnpairment spitaAized, which results in a temporary suspension of thedriving priv4e in some states, the suspension, is automatic, without regard, whet the confinement was voluntary or. involuntary.However, a pa.t,ent ng ehough judgment to seekmedical help on hiis own volition may be as safe a driver ashis =5n-hospitalized peer,regardless of the diagnosis. These cases should be individuallyconsidered.In some cases of diseharged inpatients, there May be reasonto question their futureemotional behavior which could affect safe driving.In such cases the HEWgUidelines recornznerided that there should be anobservation period of up to one yearpending restora-, adjustment will be evaluated Lion of license.After this period, their personal recommendations of the board canbe based on then current and subsequent application function.They believed it was valid toevaluate tlae driver's license ry the basis offunctional ability.The ability to maintain areasonably stable, personality was an importantfunction for safe realistic, and socially acceptable periods of ir- driving.Individuals with an emotionallyerratic pattern, showing responsibility, outward orinward aggressiveness, or distortedperceptual thoughts have been identifiedby accident investtgators,aspotentially high risk groups in motor vehicle accidents. Koschlig (1974) identified thefollowing from he newmedical guide- ,li.nes adopted in East Germany: In general, acute stagesof psychoses make theindividual un- suitable for driving.Every case should bejudged On the type of psychosis and theindividual prognosis. Goodattributes are: social adjustment,relative freedom from syMptoms,and individual's understanding ofthe disease, high intelligence,and the predominating of depressivetendencies.Negative attributes are:relapse within two years,demonstrated dangerousness or unpredictability, mania, and suicidaltendencies. When an individual takestherapeutic drugs and the sideeffects hinder driving Sufficiently, heshould not be allowed todrive.: Only in sever casesolipsychopathic personalities isit,n cessary to restrictthe driver's license.. Each casernust'be ated individually. An immediatelicense revocation isrequired upon hospitalization.Lengthy out-patient-treatmentfalls into the same category.When there is a remissionof symptoms, the license can' be reinstated. The Nova Scotia MedicalSociety (1965) maderecommendations for people with personalitydisorders and psychoneuroses.The psychoneurotic significant behavioral or drugrelated problems: The t may clrive,if he has no problem with re,- ople who have personalitydisorders represent the biggest rd to safe driving.

4"4 The American Medical Association (1968) pointed out that the severe .. ps.ychotic should be hospitalized and should not be allowed to drive.Generally, other mentally ill people should be evaluated individually; and if they have no significant behavioral problems and no deietemateus side effects from drugs, they should not be restricted from driving private vehicles. The Canadian Medical Association published guidelines (1974) which are in general agreement with the Quebec Ministry of Transport(1973).The MA recommended the following to physicians: Psychopathic Personality _ Persons who show. a complete qsregard for-accepted social values, who have a history of violent or irresponsible behavior and who are knoWn to be mpulsive with A. consequent loss of caution and good 'judgment, can be a real menace on the road. Ps.ychoneuroses Psychoneurotic applictEn.- require individual evaluation. Each case must be considered on the basis of alertness,social behavior and psycho- motOr retardation.If no significant behavioral problem exists and if there are no marked side effects from drug therapy, it is usually safe for a person to drive any type of motor vehicle. Psychoses Most persons with a serious psychia ric illness will be hospitalized. Before discharging a patient who has been treated for a psychiatric disability from a public or private hospital, the physician must decide whether the patient is well enough to drive safely when he returns home.The interests of both the patient and the public must play a part in this decision and, in some cases, an observation period at home will be required before the physician can give a sound opinion. A patient discharged from a psychiatric facility may be presumed fit to drive if the hospital or clinic psychiatrist advises the attending physician to this effect.A patient with an acute psychotic illness who is not hospitalized should not drive any type of motor vehicle. Repegted Psychotic IlnesS

. A person who has had a number of episodes of pshiatric illness presents. an especially difficult problem,. patticularly when he is.applying for a license- to drtve a Passenger transport or heavy commercial vehicle. As a genera principle, if the physic feels that it was unsafe for him to drive during any of his past episodes, it is felt that an applicantshould be limited to driving a private motor vehicle during periods ofremission only. Patients who have received electro-convulsivetherapy (ECT) have impaired mental/motor reflex, as far asthe driving act is concerned, and should not be in charge of any motor vehicleuntil clinical recovery is complete as judged by their psychiatric consultant andfamily physician. Psychiatric Drug Therapy anDriving The side effects of many drugs commonlyused in psychiatric the ra dik also produce a definite impairment in patients who might otherwise be quite capable of driving safely.When combined with alcohol these side effects are often greatlyintensified. The Uniform Vehicle Code stated that a personwho has been suifer- mg from, a mental disabilityand who has not been restored to competency canbe disqualified from having a driver's license.It also stated that when the Com- mission h4sgood_cause to believe that a personwith a mental disability cannot operate a:motor vehicle safely, this person canbe disqualified from having a license.Forty-one states have statutes comparablewith these statements (Na- ti9nal Committee on Uniform Traffic Laws andOrdinances, 0.974 and update to 1975).There were legal precedents suggestingthat insanity can be the_reason for an "incompetent person" (Wordsand Phrases, 1965).

4. Sudden III essNeurolo ic, and- Cerebrova,scular 14andica Over the years, a large number of studieshave discussed the impact of sudden illness or loss of consciousnessat the wheel. 1Their conclusions have been that arteriosclerosis(diagnosed and undiagnosed) has been the pre- dominant cause of these accidents, althoughoccasionally, other neurological or cerebrovascularhandicaps have been reported to cause theseaccidents. All told, the combined impact of these typesof impairments is thought to contribute little to, the overall traffic safetyhazard. Very little direct evidence was available aboutthe driving performance of persons with either neurological orcerebral vascular diseases. .There have been a few case reports describingautomobile accidents caused by the following concrtions (aneurysmsKeane, 1973;subclavia.n-steal syndromeMozesa, 1967;

Peterson and Petty, 1962; Somme rville1962; Hartman 1966; Hay, 1968; Grattan and Jeffcoate, 1968; Crancer andMcMurrac 1968; Baker and Spitz, 1970; Waller, 1970; Ysander, 1970; New SouthWale- DMV,197*Hossack, 1974

-46- ley, _et al, , 1969);.Occasionally other reports have-come from epidemologi- -cal studies (Norman, 1960; Herner, et al., 1966; West, et al., 146). Mere ishqw`ever, an absence of any controlled studies where the effects of these con- ditiona were observed. Driver education prograids reported conflicting data on the successful or =successful education and licensing of persons suffering from neurological disease§ or brain damage. 2In awddition, these educational programs did not report follow-up- data. on the driving performance of their clients. There was a good deal of opinion regarding the examination and sing of neurological and cerebrovascular handicaps.The Medical Society of Nova Spotia suggested that patients with inadequate blood flow to the brain, those suffering from syncope, or dizziness should be advised not to operate a Motbr vehicle.If there has been any cerebral vascular et.isode causing changes in personality, alertness, ability to make decisions, IA if there has been actual loss of motor or sensory power or coordination, these patients should be ad- -wised not to operate a motor vehicle.However, if sItich changes are minimal, they said it may be possible for these individuals to drive private motor ve cles. Both the Canadian and American Medical Association generally agreed that it would be impossible to cover all the disorders which may produce faintneSs, syncope and episodic weakness.They stated that it is the pattern of symptoms which must be evaluated in terms of impairment of driving ability_ . While isolated occurrences are probably of little concern they recommended that persons with-histories of multiple occurrences be advised not to drive unless corrective measures can be implemented successfully. Both Medical associations agreed that the neurological disorders affecting muscular control or coordination and the chronic brain syndromes affecting consciousness, memory, judgment or motor power pose special-prob-

_:- lems with respect to driving.For such conditions, both groups emphasized that it-is functional capacity of the individual which should be evaluated with the physician using his logic and common sense as well as his knowledge of pathological physiology in evaluating the individual client's ability to drive.

ZBerner, 1968; Reynolds, 1968; Hofkosh.,let al., 1969; Mathias, 1972; .Poor, 1972; Long, 1974; Odhneri 1975; Selwyn, 1975; Steen.srna,.&1975; Sullivan, et al. ,1975; Ramsey, 1975; Uric, -1975.

-47- The USDHEW Public Health Service guidelines(1969)` seed that for any condition that causes episodicalterations of consciousness the examining physician should recommend licensing as described by the tablebelow.

Table 1.Alterations of Consciousness and Acceptable Levels of Function for Driver Licensure

In w Group Passenger Cargo Private Periodic Limited Trans i,ort Trans Auto Reevaluation License

yes yes yes yes no B no no yes yes .no no no no yes ye s

Nocturnal epilepsy and 'stress hypoglycemia. This table covers lapses or alteration of consciousness which are from CIS Publication No. 1996 severe enough to cause the person to losehis poStural attitude or to be unable to continue whateveractiori,he was involved in.Isolated, incidents without likelihood of recurrence should be discounted. Individuals suffering from one episode of altered consciousness should be grouped as follows: Group A -- Individuals who have not had an episode of altered consciousness for the preceding three years; Group--Individuals who have had an episode of altered consciousness in the preceding three years but not within the last year, and Group CIndividuals who have had an episode of altered consciousness in the preceding year. They noted that persons suffering from arterial and arteri -ye aneurysms should be considered separately sincetheir symptoms Maio not interfere with driving.Central nervous system aneurysms must be"-yen special evaluation since they present a.very high. risk.In-general, they recommended that such individuals not be recommendedfor a private vehicle License; certainly not for cargo and transport licenses. In West Germany, all cerebral disorders weretd be.evaluated Bilkanyi (1971).The physician was instructed to investigate the cerebrovascular insult, the possibilitias of treatment and then evaluate theremaining funational abilities of the person.In Switzerland (Hartmann, 1971) physican guides empha- sizedIthat persons are not allowed to drive if they suffer either from any nervous disorder causing permanent disability or frOm anycondition causing a'periodic loss of consciousness. Waller (1973) summarized that cerebrovascular. disorders are likely to impact on driving in three ways: Single or ep sodic-loss of conscio ess._ Temporary or permanent paralysis of a s and legs ail well as .possible changes in vision and hearing. Changes in personality judgment or me ory He felt that most persons -will recover sufficiently fromthese conditions so that, often, severalnionths to. a year later they can drive with if they have been fully evaluated.He suggested that the examiner pay particular attention to any erratic behavior in-the person's life which may besuggestive of altered thought processes. Once these persons resume drivinghe suggested that they should remain wider rried3cal surveillance with the results being sentto the motor vehicle department regUlarly for several years For other chronic or recurring conditions affectingcoordination 'Waller suggested an annual driving examination by road test.Since episodes of temporary disability occur irregularly,medical examinations were required either yearly or after each episode. Traumatic head injuries also must be carefully examined to determine if there is any evidence of confusion which couldrender the person'temporarily unable to drive.The Canadian Medical Association (1974) felt that while minor head injuries should not impair driving ability for morethan a few hOurs, a more serious injury resultnig in even minimal residual braindamage, must always be fully evaluated for its impact on deriving.'Some factors that may prohibit driving for an extended period are loss of good judgment, dtcreasedintellectual capacity, post traumatic seizures, visual difficulties and loss ofmotor power.The Cana- dian Medical Association suggested as .a guide that any head injury,patient with post-traumatic arnnesis of two to four hours duration, should not drive anymotor vehicle for at least three months, and a Medical examination shouldbe required 'before driving is resumed.. In. the United States there is legal precedent for thel corns of persons with these handicaps.All but ten states followed therecommendations of the Unfform Motor Vehicle (ode and have statuteswhich stated that the motor vehicle department shall not issue any driver'slicense to, nor renew the driver(s license 'Of any person: a) who has previouslybeen adjudged to be suffering from any mental disability or diseaseand who has not at the time of appli-, 'cation been, restored to ,competence bytemethods provided by law; and, b) when theeorrunissioner has good cause to believe that such person,by reason of phy sical-or mental disability, would not be able tooperate a mo ovehicle with 'safety upon the highways. The courts, in considering conditionscharacterized by sudden attacks which could result in loss ofconsciousness, have placed particular'emphasis on the perion'smedical history and the relative frequency withwhich the motorist has suffered attacks in the past.In one, case a revoked license was or- dered restored to a person who suffered from amild brain atrophy which had' caused a faintinginciderNwhile he was driVing.- The court noted that he had suffered only two previous falilting attacks inhis life.They haVe-also considered whether the person isable to predict his'moments of disability with advance warning symptoms. Aiso several licensesuspensions have lf!e.n reversed where a person, suffering from a spasmodiccondition and possibly other neurologic irregularities would, in the opinionof a doctore always receive enough warning to enable him to stop his car...-Also therePhave been cases where in the c'ourt's opinion neurologicalirregularities have.not contributed to a traffic safety hazard becausetherapetitic medication was capable of controlling these neurological irregularities(American Law'Reports, 1971). There have been cases where thecourt has ruled that the person would be a traffic safety hazard.One case Mvolved the absence of any competent -medical testirriony about the existenceof two bullets remaining in the patient's head. There was some information can the educationof persons suffering from cerebrovascular and neurological conditionswith most programs reporting vary'- ing degrees of success.Reynolds (1968) described the difficulty1ofteaching high school students with brain dysfunction(cerebral palsy) compared-to teaching the orthopaedically handicapped or the delicate(hemophelia).The problem was not in the teaching of the"rnechanical skills"but, rather, iri identifying and compen-- sating for the brain damage or dysfunctionwhich often accompanies cerebral palsy.Brain dysfunction or functional deficts inperceptual and mental processing is often mentioned by personsteaching driving to the neurologicaLly impaired (Hofkosh, et al. ,1969; alhner, 1975; Ramsey, 197,5; Selwyn,1975; Sipajlo,1 975; Steensrna, 1975; et al.,1975). With regard to hemiplegic persons in .particular,. there was some die- cussiorfin the literature about patterns of percePtual and motor performanCe of right herniplegia (left hemisphere brain damage) and left hernipleKia (right hemisphere brain damage).(Barda.ch; 1969; Long, 1974; Sullivan; et al., 1974).Flofkosh, Sipajlo, and Brody (1%9) suggested that, in.patieitswith elerate brain damage, left liemipleiics demonstrate subtle, to obvious perception or spatial relations difficulties more often than do right hemiplegics. 'Other authors agreedbuttwith qualifications (Diller and Weinburg, 1968; -van, et al. ,1975; Ramsey, 1975).Studying hen-iiplegics, Diller and Weinberg found the.pattern of performance deficits for both visual and auditory tasks to_ vary, they hypothesized, with the Usage 'of either shOrt-or long-termmeniory., Diller (1969) stated that, while brain damage always occurs herniplegia, behavioral functioning is,not always adversely affected.. He felt that thode, who demonstrate "organic" traits will be more likely to have more severe percep- ual, cognitive and eznotio- 1problems. All authors agreed that each cafe must be evaluated individually. Bardach (1971) amined the psychological factors, associated with the education of 31 patinas rated as "difficult" by their driving instructors. fir the brain-damaged patients she noted that perceptual-motor and cogni-- tive problems occurred more often than body image or emotionalprbblems. Left hemiplegics seemed to demonstrate cognitive difficulties in inadequate visual scanning and in an inability to shift with the changing demands of the driving task (distractibility or confusion).The right hemiplegics did, not appear to-demonstrate impafrments functionallyrelated to the driving task.Sbme driver education programs report teaching visual scanning procedures which appear to compensate for the losscif visual field due to brain damage. The greatest difficulty as Reynolds (1968) noted, was the early diagnosis of these perceptual or visual problems.Sipajlo (1,969) described several behind-the-wheel maneuvers which brain-damaged persons without compensatory training have difficulty completing.These included driving in clockwise and counterclockwise circle patterns.These circles were followed byfigure- eight maneuvers which seem to be useful in the 'evaluation of driver planning,, perception and coordination.The figure-eight maneuver was reported by several other handiCap driver education programs (Qdhner, 1975; Ramsey, 1975, Sulli- van, et al.,.1974).Sullivan has .described in. detail a test battery which was created to evaluate the brain-daniaged person's readiness to drive.The test takes one hour and can be adrninistered.by a qualified occupational or physical therapist after a short training period. TN test consisted of six separate evalu ations: physical considerations, perceptual tests, lariguage tests, visual testS, reaction time and general attitude and behavfor.Test results far 88 clients showed a high correlation with a behind-the-wheel evaluation administeredby the institution's driving instructor. Ep

According to. Epilepsy Foundation (as seeninArthu been paid to the licensing of epileptics Litottithee' 1970), more attention . licenspag of persons wi4sany other cliseasesancludmgalcoholism. rtun- ately---4-nostistudies of epileptic driving behavior do not differentia e een E. . different forum of epilepsy. There are several-types (Waller,1967; Northcioft). Grand mal epilepsy is both the mostprevaient and the most incapacitating.In this-condition; the grson,losesconsciousness_ and,' has convulsions. Forsome. in- theeiztire may be preceded by aWarning.sensation or aura. An- other-type is petit real epilepsywhich.IS distinguished by frequent brief losses of seonsciousnets withoutconvulsions.This Andition is rarely-associated with an aura. Poval or. Jacksonianattacks are characterized by convulsions starting in or limited toot areaof the body (e.g., a leg or hand)..-Such a seizure may progress tinvolve the entire body. Psychomotorseizures in- volve the temporal lobe, of the brainand are frequently associated with personality changes. The attack may appear as abrief attack of insanity.or a brief trance. .Sometimes grandmal convulsions alsci occur.Finally, there is a variety of lessprevalent types,of seizureincluding inyoclonic, drop and hypothalamic epilepSy Hierons,' in 1965, cited a number ofindividual cases in EnglandIrhere epileptics have caused V4/fie accidents.This opinion was supparbsd y Ch (1972) who stated that uncontrolled grandmal or petit mal epileptics werelikely" to be involVed in more than oneaccident and that an attack might occur,at any C. A few mare rigorous studies havebeen reported.In one study of 42,255 reported road accidents(Hemmer, et al., 1966) in Sweden from1959- 1963, 41 accidents were caused by suddenillness of the driver.Of these 41, 10 were due to epilepsy--or one for every4,000 accidents.Davis (1976, as seen in EpilepsyFoundation of American, .1975) studiedthe driving records of 77 Oldahorna licensed epileptics.He found that the male epilepticshad ac'-. cident rates three times higherthan all 6ther licensed drivers:The females also.had higher accident rates but lower violationrates.' Ex'ercising some statistical control in their study, Crancerand McMurray (1968) 'studied the accident and 'violation rates of 39,242Washington State medically restricted drivers.The group of epileptic drivers hadstatistically higher accident and violation rates than allWashington's 1.6 minion licensed drivers.In Cali- fornia, Waller (1965) compared epilepticdrivers with a statistically weighted control group of normal drivers.The epileptics had twice thenumber of accidents per million miles and 1.4-timesthe number of violations. Waller studied he accident and violation rate ofpileptic dr - veFs whose seizures-weie less serious (always occurred i were always preceded by an aura or were always petit mal). driving performa.nec-,was compared to epileptiFfIrii`lers whose seizure Were more serious. Although there was a'trend toward' fewer accidents am ng drivers who had noc- rnal seizures, auras, or pAit mal seizures, the samples were small and the differences were,not statistically significant.In conirast to studies finding epileptics- having higher violation rates,, Ritter and Ritzel (1972), in West Ger- many, found that the 546 epileptics they studied had fewer traffic violations than the general public. cording to tie -Epi.lepsy Foundation of America(19?5) the:.niedication used becjileptics may *ause 'Sedation and by itself could be the eause,,a s.Doke rt (1970, East Germany) was of the opinion that antiepilisptic drugs dered driving somewhat. He felt this negativeeffect was TricreaseId with the use of alcohol.In a survey of 100 patients whoseepilepsy was a drug resistant poFal-lobe type who had' an anterior temporal lobectomy three to .en years preVfou sly, -17alcotier and:Taylor, (1967) found that 13 of the patientswere driving motor vehicles; and in their opinien.; 26 othett ,could reasonably apply for licenses.

There were Many differing_ Opinions regarding-the_ licensing of epileptics,A survey in' Great 5ritain (Fahemieter, 1961) found a significant.numbr of individuals (ZS or 130 surveyed), with and without licenses, who were driving and liable for recurrent attacks.Thepe people drove despite warnings froth their doctors. Imriets (1972) thateople who have epilepsy should only be allowed to drive if their physicians felt that they were unlikely to have a seizure. He felt that it was not justified 'to license an epileptic simply becuase he had been free from a seizure for two or three years.In a British=article, Espir (1967) stated that only one year conditionalIicenses for private vehicles should be granted and then renewed only after Meslical reassessment.In these capes, the applicant must provide vWriiitten sxatement that-his prescr bed-treatment will be followed regularly and with,ifie understanding ,.that:; not . , Permitted if freed tre4.tMeht Was discontinued, !if medication was omitted,. or if anotht ire occurred'.In Austria, S1ugaA1968) concluded that an individual wht, seizure free for 1.3 years without-medication (five years with m-dication), cuuld-demonstrate a normal EEG, and passed a psychiatric examination or psychOlogical personality profile should be allowed to drive. Balkanyi (1971) suggested that licenses be granted two years after the st seizure.Ransford (197) disagreed and stated that the two-year period was severe.' Kuhl and his associates (1967) disagreed also.In follow-up studies

-53- 173 patients, who had the onset of epilepsy afterthe age of 17 and history of urestnot exceeding five`Years, they concluded that the very strictrules for the licensing of 'epileptics are inappropriate.They recommended that in certain, cases of epilepsy (thosewellUnder control, those with a good medical progno- Sis, aria in 'cases of epilepsy With adultonset)-",' a pe.riod of three,months Without Seizures was sufficient for ptivate licensing'. Forcommercial licensing, they suggested stricter medical control andlicense renewal_ after one, two and five.

pilepsy Foundatio-nof An erica.(1975) suggested,after a review of the literat-ure on epilepsy and driving,that epileptics be evaluated on in in- ,diiidual basis. They felt that licenses shOuld beallowed upon the examining phydician's statement th7t the driver was under rneelicatiOnand free from sei- ure,s.Further, temporary licensesshould be permitted for three to'six month witkpermanentlicensure after two seizure-free years.The American Medical Association's (1968) phys'ician's guide_recommendedthat epileptics could drive private motor vehicles after oneseizure-free year if they-reliably took theirmedi- cation.They recommanded that epileptics shouldotai drivecommercial or pa.ssen- gc, rtransport vehicles.- Also each individual, regardlessof his prognosis, sho ld be medically -elvaluated every- six-months The Canadian Medical A ssociatio (1974) guide for physiciansreeorruriendecl that an epileptic:1) who had been free from:seizure two years; 2) who wasconscientious in taking his medication; 3) who did not have medicationside effects which impair driving; and4) who was --wider -rnedicalsuper-asioncould usually 1-ipe*rate a motor vehicle safely. ever, an aa epileptie should not driVe apassenger-transport or heavy cornnlercia: :vole. Table 2 summarizes the recommendation tomedical advisory boards r alterations of consciousness,whicliincluded epilepsy (LS. D. H. E. W., 1969).Group A are individ als who have nothad an episode of altered con- sciousnass for the precedi hree years. Group B are people who havehad an episode tsf alteredconsciousness in the preceding three years but notwithin the last year. Croup C are those who havehad an episode of altered eonScious- ness t e preceding year.

-Tabl Alterations of Conscipus_ness andAcceptable Levels of. Function for Driver Licensure

IIE Iv v a _, up Passenger Cargo Priva Periodic Limited Transport Trans +ort Auto Rdevaluation License

A. yes e s, yes yes no yes no no no yes a C no no no yes yes rnal epilepsy and -s hypoglyce -54- According to Arthur D. little (1970), .in most countriesthat required a driverlicense-, even the possibility of an epileptic seizuredisqualified an individaai from driviang.However, ,a large proportion of epileptics drive any- way. 'Ritter and Ritzel(1972) noted that Eastern European countries havestrict regulations concerning epileptics while Scandinaviancemtries teed to issue licenses to epileptics because they felt thatepileptics woad ,drive even if they are not licensed.III contrast, Denmark(Adserballe, 1974) did not allow epileptics to drive.In East Germany, the new medical-guidelinesrequired two years free from seizure, nons ofunsuitability for driving (medication incapacities, vision or- coordination problems,etc.), and yearly phyoi- cals incluc'ting EEG' s .Epileptics were not allowed to drivecommercial vehicles Koschlig, 19741. Before the Vehicle and Driver Licenses Act of1969 in England, person admitting to everhaving epilepsy was not allowed to drive (Raffle, 1971).This new law stated that a licenseapplicant who is anepileptic must satisfy these conditions: he shall have been free from any epileptic attack w for at least three years from the date Arhenthe Lice effect; in the se of an applicant who has hadsuch attacks whilst asleep, during that period he shall havebeen subject to such attackssince befog the beginning of that period; the.d lying of a vehicle by him in suance of helicense is not likely to be a source of danger e pablic. According to the Quebec Ministr POrt (1973): "Persons who, although suffering from a type ofepilepsy and whether they take medication or not, have not had anattack for more than. two years, may usually drive aprivate vehicle whose maximum curb weight does not exceed 6,000 sounds, as long asthe medication the y take had no undesirable side effects whichmight impair their capacity to drive." Manus and Less (1972) in studying the licensingpractices of the noted a trend toward conditional or restrictedlicenses for persons affecteby unstable, chronic medical conditions.

-55- Seventeen - states have laws which Prohibiled cerfain eppis from being licensed to drive (National Committee onthiiforrn-IT c- I rs a Ordinances, _. . .. 197'5).These states.' restrictions ranged from not ing 4n epileptic to drive at all to restricted p.riviledges.Usually a physiciati tatemeut is required 'cer ying that the persorewas sunder medication and,free from seizures or under medical supervision with two seizurefree yearsprior to the. licensing. There were several legal precedents concerningepileptics licensing (American Law RePortd, 1975).In one case,,(1942) the court stated that there was common agreementthat an epileptic per'Son would be considered incompetent or unable to exercise reasonable andordinary-control over a vehicle. This statute allowed Miministra.tive suspensipn of.ifipepileptic.!s license.In another' case ,(1956), an epileptic's license was notrenewed.when it was ascer- tabled. that he had one seizure within the prior two.years.'He was rwired to submit proof of two years of seizure freedom without useof medicatio .There was also precedent fromtwo cases (1962,11965)where failure,44 to take prescribed medication (thereby increasing the potent of having a seizure) was supportive upholding licenseAtTspension. In 1970 an individual whose license had not been'restored by an ad- ative licensing board,,was, grtad restoration of his license.by the d20-sie story of epilepsy with at least seven 'court.. EVeri4though he e seizu es,"i>ehis accident free-three-Year driving record(75,000 miles) and controllatility."of his disease by medication was sufficient evidencefor restoration of driving privileges.In 1954, a mild epileptic had his.licenserestored by the court.because he had warning prior to his seizures,had suffered only three seizures in 11 years, and because he had supportiven'iedical testimony that he could be a safe driver if he continued hismedication. the epilePtic -: There was alniost no information specifically, concerning and driver education.Kirk (1972) stated that the,need for special. classes and schools for epileptieS 'was disappearing.- ' The_ majorteadon for these spe cial,Ielasses was the problem of handling'con-viiisions duying the class. Modern medidation.hadlnow made epilepsy more contrbilable.,Glenn (1975) had iden- insurances fit-led .one. cbmplication.By state law in Ohio, epileptics must have . be'fore they take driving lessons and must filemedical report every couple of rn;oi11'S.

iabetes (Ameri9.n Diabetes Association, 1966) is a medicalcondition which the body cannot utze and properly store glucose.In, uncontrollable diabetes, diabetic, coma. and/ordeathis possible. Diabetes often can be controlled

-56- by proper diet and/or insulin orother drugs. When insulin treatmentis necessary the problem ofinsulin-reaction may-occur.. A reaction can cause toms ranging from lightheadednsssto loss of consciousness. Emara (1969) performed a surveyfor an Egyptian traneeportatlon.coriat y.His conclusion, based on106 'employed diabetics, roas t tre was not gnificant incidence -©f motor car orbus accidents. :la,Wn Or ashington, D. C Departriient of MotorVehicleg, 1973)rindom selection of raffic records for 150 diabetics(out of 1,153 diabetic drivers) were ompa.red to all r).cfdelvers.Diabetics who were under adequate medical ma=ement had better and safer driving records.Helmer, et al., (1966), reporting on an area of SWeden, fountonly three incidences of accidentscaused by diabeticq ith lryToglycernia.This was out of a total42,255 .road accidents invest iga,ted b olice in 19597063. In a well controlled study comparing256 diabetic drivers with normal drivers in Sweden, diabetics hadonly 5% as many accidents and69% as many accidents combined withserious traffic offenses (Ysander, 1966).Later, Ysander (1970)reportea comparing 219 drivers' withdiabetes who were not required to have regular medicalexaminations to a control group (matchedfor age, sex, driving licenseperiod, andeximasure).Twenty-one perFerit.of they diabetic drivers did not drive at allbecause of the disease or -its,conrplica.tions. Over a 10-year, period(1955-1964) for those who did drive,rio accidents or traffic violltions-Opcurred as aresult of the diabetes or itstreatment. Also, there were fewer accidents rightafter the beginning of theillnesaithan there were for the total 10-year'period for the diabetics.He concluded thatdiabetics did nottonstitute anincrease In traffic risl.He suggested that the awarenessof the disease may be a good prophylacticfactor from a traffic safety point ofview. In a somewhat, controlled studyof 346 diabetic drivers on PrinceEd- ward Island, Canada (Campbell andEllis, 1969), diabetics had 1.7 as, many dents and many morecOnvictions than age-matched non-diabeticcontrols. conviction repeat- tkeze Nifere three times a.s`rnany accidents, and major study (Crancer and Mc- _ among- diabetics.In another somewhat controlled Murray, 19 'over 39,000 Washington State medicallyrestricted drivers The diabetics were comp ,red withthe Stats`1.6el8), million licensed drivers. had both"gher accident and violation rates.Waller'-s,(1965) study of 2,160 persons with chronicmedical conditions, comparedwiai 926 other California drivers, indicated that diabetics had78% more aOcidents and 39% moreviola- tions per million'iniles than theage-adjusted odntrol group. lmrie's (1962) opinion was thatdiabetics are a risk only if they take insulin. With insulin takers,there was a problem of hypoglycemia andloss of

-57- conseiousness.If a patient waa subject to hypoglycemic tucks, it waa better he did riot 4rive..Brandaleone (1963) generally agried betic on insulin had frequent indiain reactions,, he should not drive.In East Germany, Dokert (1.970) suggested that if the diabetic is under control with insulin or an-' `,if-diabetic drugs, 'thene should be allowed to drive.Campbell end Ellis (1969) found in their stiid that the type of insulin therapy didnot seem r any significance to thc,,involvement of diabetics M. any particular ceidents, although-their'a4ccidents and violationhigherrates were ,, (--1

Ll '* *aller (1973) felt hatlidiabetics Should not he allowed to drive..fdr 18 to 24 months after their last insulin'reaCtion. -He_also stated:that compli, ons such as arteriosclerosis and-vi!stal changOS should--prevent them from driving unless the asseciateci-Co.nditions are mild.The American Medical Association (1(i68) and the Nova Scotia Medical Society. (1966) thought that medical exarnitestion should be required if a license applicant has diabetes and takes insulin and had not been medically evaluated during: the 'past year. The AMA 'went further in its physicians' guide'` .068) to say that a diabetic, controlled by diet and a sulfonylurea drug,- may drive any motor vehicle. Pet sons.on insulin could drive private but not commercial vehicles,- and the tm- controlleddiabetic .should not,drive at all_Raffle's (1971p option iva,s that diabetics 'controlled bi.diet and oral-hypoglycemic agent's, had a small risk of prolonged hyRoglycernia, and they shouldpin ably-. not be_ailedow to drive buses or vehicles that, carry heayy goods.. ;141-%9,, thoge who boa insulin-and, ,drove with symptoms of hypoglycemia could be charged With driving under the influence of drugs.. The Canadian Medical Association (4974) agreed -t. diet.or diet and oral medication could drive' of motor vehicle safely if they were under regular Medical superatios also said that those,who required insulin but o were -under,. good, control and , .r. - ,. - were not subject--hypoglycemia. , reactions. coa drive pH's? and light cO mercial vehicles. - . f For drivers who developed hypoglycemic reactions. they,.sugested no driving until, this complication was under control for at -least a. month. They sh"ould then remain under close medical supervision. Table 3 summarizes the recommendation to medical advisory boards or alterations of consciousness, which included diabetic hypoglycemia (II. S. D. 11.: E. W. ,1969). Table 3.Alterations of Consciousness and Acceptable Levels of Function for Driver Licensure

I II III V oup Passenger Cargo Private Periodic ed Transport Transport Auto Reevaluation License

a, e Noc urnal epilepsy and stress hypoglyce ke, Group A are individuals who have hot had an episodeof altered consciousness for the preceding three years.Group B are people who have had an episode of altered consciousness.in the preceding three years but not within the last yearGroup C are those who have had an episode of altered consciousness in the preceding year. Less and Manus 1972) reported that the trend in the U. was to license applicants-with stable diabetes while restricting driverswho artunstabtkA number of states required diabetic drivers to submitregular m$dical rep rts-- Washington, D. C.Maryland, North Carolina, and Pennsylvania.,-forexample (Washington, D .Departmeof Motor Vehicles, 1973). There were also two legal precedents (American Law Reports,updated 1975) for restoring licenses to diabetics whose diseases wererelatively controlled and who had warning symptoms prior to insulinreactions. Howev r, if an individual was subject andlikely to lose consciousness from a rnediezcondi- tion, he might be charged with negligence (CorpusJuris Secundtun, 1975). Narcolepsy Most narcoleptics go undiagnosed; it is a fairly commondisorder (Yoss and Daly, 1963). Waller (1973) disputed this.Yoss and Daly described the nat..- coleptic tetrad: 1) excessive,,sleepiness (narcolepsyproper), 2) cataplexyrnus- cular weakness induced by 3) sleep paralysis or attacks of transient inability to move in the sta.between arousal and sleep, 4) hypnagogic hallu- cihationsduiring drowsy state.They found that 25% of their large number of patients had symptom 1; 64% had 2; 28% had 3;30% had 4; and only 14% had all symptoms. There was an effective drug treatmentthat usually kept the condi- on under control.In questioning 100 narcoleptic drivers Yoss and Dalyfatmd: Ninety-eight adrtted episodes of dt mess or actual Bleep while driving. Fourteen actinid one to .six accidents as a direct result of falling alseep. Seventeen came close to serious accidents when. they fell asleep and ran offe road. Many pulled to the side of11 road and slept or walked around towake up. Since there is drug treatment that usuallykeeps the condition wider control, they concluded that narcoleptics could drivewhen their treatment is effective. the patient stops treatment, they recommended that he should stopdriving for years and resume driving, if there were no moresymptoms. Barteks and Kusakcioglu (1965) compared 115 driving narco e patients with a normal group (105) matched for sex and age.They found: venty-seven percent of the narcoleptics suffered from undue owsiness while driving and only 14% of the normals admitted drowsiness. Forty-two, percent of the narcoleptics had fallen asleep while dri wing as compared to 7% or the normals. Only 0.9% of the normals had an accident as a 'result of falling asleep while drivir.1,, while 17% of the narcoleptics had.

Fifty percent of the n oie ptic s -a void Yoss (1969) reported that he had developed a test to measurethe five stages of wakefuess-. His ten-minute test was based upon studyingthe'pupils' diameter and eyelid behavior in oAigr ZOO persons.The test has be_ en able to discriminate between acicnowledged,unsafe sleepy drivers and safe driverS. In regard to licensing, Ransford11972) reported that more research was needed on narcolepsy beforelicensing guidelines could. be made; Ballcanyi (1971, West Ge =any) stated that it was dtflicult to diagnose a narcoleptic.Waller (1973) felt that a narcoleptic should have his license restricted alongguidelines sirmililt to those used for epilepsy..

-60- The narcoleptic could, drive if he has not had an attack for m two years, whether he was taking medicine or not.If he is taking medicine, no undesirable side effects are allowed (Nova Scotia Medical Society,1965; Quebec Ministry of Transport, 1973).According to the Canadian Medical Association (1974), narcoleptics should not drive until they are 'free from attacks for three months and are experiencing no side effects.They then can drive only private vehicles.The new.medical guidelines from Eras(ermany (Koschlig, 1974) recommended that the narcoleptic can drive a piiVatetye cle if the disease has been successfully treated and no medicine is cessary. However, EEG examinations have to be made every six months. Table 4 summarizes the recommendation to medical a.dvisory`boards for'arations of consciousness, which would include narcolepsy (USDHEW, 196 Alterations o Conscir,AI aess and Acceptable eels of Vuric for Driver Licensure

III V Private Pe riOdic Limited Auto Reevaluation License

yes yes ye s yes no no no- no yes yes a no no no ye s yes

N urnal epilepsy and stress hypoglycemia. Group A are individuals who have not had an episode of altered consciousness for the preceding three years.Group B are people who have had an episode of altered conscioueness in thepreceding three years but not within the last year.Group C are those who have had an episode of altered conscious- -ness in the preceding year.

Tire were legal.precedents that may make adriver who falls asleep at the wheel guilty of negligence or even gross negligence (Corpus Turis Se- cundum upcifted to 1975).He would be considered negligent either in allowing himrlf to fall asleep or in.continuing to drive while in danger of falling asleep.

4.4 Vertigo. -`,,There were only four reported cases of patients with vertigo being in volved accidents caused by this condition.Norman (1960) stated that in the

-61- London Transport for 220,000 bus driver years, there were two casesof lar- yngeal vertigo in which the drivers became unconsciousand were involved in an accident.Mozes (1967) reported two cases ofautomobile drivers causing cidents who had subclavian stealsyndrome which produced true vertigo.

There were several expert opinions on vertigo and licensing.brie (1962) stated that people-who suffer from labyrinth impairmentswith attacks of vertigo and blackouts should not drive. Hartmann (1971)reported that the new Swiss regulation recommendedna driving for people who e rious diseases of the inner or middle ear.People with Meniere' ..frne who suffer from vertigo without warning should not drive until has controlled such attacks (Nova Scotia Medical Society, 1965 ;,A Medical Association; 1968; Canadi Medical Association,1974) u dfviduals with any acute labyrinthii.L., or_ positional vertigo should beadvised not to any type of vehicle until theircondition has subsided or-responded to treatment (Canadian Medical Association, 1974).

9.'Cardiovascular andrculatory Diseases. 'There are many types of diseases related. to theJleari and/the tory system. The literatureconcerned with driving behavior a.nd,driver licensing was not consistent in its treatmentof these diseases., The literature, con-- sidered such diagnostic categories asarteriosclerosis, .h.frpertgsion, cardiac arrhythmia0L;congestiVe heart_failure, congenital heart diseaste Rayhaud.'s phenornenon,4and others (Waller, 1973).Heart and circulatory proble.eis be more prevalent with increased age presenting anadded coneern-fqP Per pie in the traffic safety field (American Medical Ass_ociation,1974). Baroody (1970) -mentioned several conditions which canafiect the driving of patients with cardiac problems. Exposure to cold caninduce 'angina in some patients.with coronaryatherosclerosis and coronary insufficiency. bents with Raynaud's phenomenonma.tAvelop blanching and cyanosis of the hands and fingers. An excessivelyhoeenvironinent can also cause increased Aress or difficulty in body temperature_regulationspr.People with cardiovascular dise'ase.Simply a sudden-turni-ng of "head andineck can affect the CA- vertigo.mild pre-existing ver- rotid or verteprobasilar systems -and.. may c tigci can be aggravated bye sudden distortion of the visualimage--such as wind- -shield distortion.Patients with Stokes-Adams syndrome, borderlinecongestive heart failute, and severe disease involving the vasilacarotid artery systems should exercise caution in driving since they aresusceptible to alt'erations of consciousness.

-62- Brandaleone (1963) recommended that peoplewith aortic stenosis, congestive heart failure, carotid, sinussyndrome, 'StokeS-Adams syndrome, or any other cardiaccondition which might 'Suddenly incapacitatethem should not drive. Cheetham (1974),_ rep_ortirig in South Africa, stated that certain individ.uals are more likely to be involved inaccidents ''They are those who are likely to have a heart attack at any timewithout warning, especially under duress and fatigue or those who suffer from severehypertension and who have a great deal of internalizedhostility and aggression. Several articles have reported studies ofthe cardiac stress under various driving conditions.Hoffman (1963), in Germany, reported that, in general, data suggestedthat a myocardial infarction can be provoked by the stress connected with the operationof a vehicle if the coronary arteries have suffered previous damage.This could cause accidents.To verify this, Hoff- man (1963) analyzed theblood circulation changes in-different, trafficsituations by means oiA.telemetric system. Hecompared the data for 400 healthy dri-, very to the data for26 'ilii'Vers;With manifest coronarnsufficiericy:H No differences were found in pulsefrequencies butlgnilicant differences were found in EKG and blood pressure. He concludedthat, at least for drive'rs suffering from angina.,Rectoris driving a vehicle is a safetyriski.:1-Io i i (1966)verified this in another.Study where he found similar results. docu- mented heart disease, Bellet et al.(1968) found s g °pardi+ ogrephic changes while driving.These wereischermc S-T- 21, rriultffoca mature contractions, and ventricularbigeminal or tr rh subjects, except for a variable increasein heart rate,dp ificant c csfr Little et al. (1973) found results whichcontradicted pieitititt* They studied, continuously, fivenormotensive subjects, five hypertensiv suk- jects, and five people with angina. pectoris,who were either hypertensive or-. morrnote9sive for Z4 hours~'' 'Observations weremade of direct arterial pressure and electrograms during 30separate drivint episodes.In all but ripe subject, apart from variable changes the heart r'- no significant arrhythmias or S T segment 'changes wereobserved.The aerial pressure remained relatively 'stable for all -persons, and there was nosignificant difference,between levels of blood pressure at the beginning and endof a journey.There were short periods of raised arterial pressure duringdriving related to episodes such as overtaking, but these quickly returned to baselinelevels.Kellerman et al. (1971) generally supported these data in their research.They found coronary patients were capable of energy expenditures at over twicethe levels calculated as being needed for motor vehicle driving in the cityduring peak traffic. Ysander (.1970) concluded that sudden illnesswhile driving has Gen proven to plp.y a minor rolein traffic accidents.In investigations tang into account the causes of sudden illness, cardio r diseases predominate. He cautioned on coniparispn between s:-.udies:h research samples are usually hetere-riecius; the studies do not have adeq eontrol groups; evaluation of r.e- sults of studies from different countries were not comparable because they have diffe ent health requirements for licensing.In support of Ysander's major point c erning the prevalence of sudden cardiovascular illness causing accidents, Herner et al. (1966) found only 10 of 42,255 road.accidents to be,caused by diovascular problems (myocardial; infarction- -7; arteriosclerotic or rheumatic heart disease with Stokes-Adams sy-ndrorne --3). Ysander.(1966) studied 612 drivers with chronic diseases in Sweden. He found that those with Cardiovageular'disease had rrAny fewer accidents than the normal control group.In Washington, D. C. ,it was found that drivei.s with coronary heart disease had better driving records than average.The hyperten- -sion group had poorer' records (Washington, D. C. Pepartment of Motor Vehicles, 1973).Crancer and McMurrary (1968), in the State of Washington, found that persons with heart disease had slightly higher accident rates(but not statistically significant), when compared td-the unrestricted driving population in the state. The heart group did have fewer violations.In studying the driving records of drivers with-cardiovascular disease; Crancer and Quiring (1968) matched them for sex and age with a control group.The heart group had a higher violation rate but an accident rate equal to the normal driver.Waller's 1965 study in California 'reported the drivers with cardiovascular disease as,having 1.6 times the number of accidents and 1. 3 times the number of violations than expected. On the basis of medical records of 600 persons with circulatbry illness, ann (1965), in Switzerland, came to the following cpnclusio oronary heart valve defects' and heart deformities- -forpetople who have initral or aorta valve defects there is an increased possibility of circulatory insufficiency or acute heart crisis.In the study .these people drove as well as normal drivers. Angina pectoris_ infarcts- -for these personsere is a possi bility of, seizure or acute heart syncope.Information was incon- clusive about their driving ability. Vascular disease-=the driving performance was good for those with slightly eleVated blood pressure. krteriosclerosis-- --n cause various, conditions which affect driving ability.

-64- Circulatory insufficiency-or se_ who also. have a. deterioration of general health; tilt-- re can be difficulty in driving. Crancer and OrNeallA19-u) randorri. yt selected -groups of drivers with arteriosclerosis, hypertensidieurnatic eart disease, and other heart diseases and compared them to non-r stricted drivers matched for age, sex, and city of residence.The arteriosclezotic and ie hypertenSive disease groups were found to have significantly higher iccith-,nt rates than non-restricted dries Vers.The rheumatic and other heart disease groups had the same number of accidents as, the non-restricted group.The violation rates for all groups were compars.b. A number of studies were based, on autopsies of drivers who die at wheel.Of 225 single motor vehicle fatalities in an Ohio, county, 57 were classified by autopsy as-natural deaths (Gerber et,al. 1962).Fifty-three of the 57 died of cardiovascular disease (43 were due to myocardial infarction).Peter- son and Petty (1962) reported on the_autopsiee of 237 driverfatalities for all causes in Maryland.. Eighty-one drivers died of natural causes; of these81,, 36 were invblved ill accidents.Ninety-nine percent of all natural deaths were due to cardiovascula.r disease. About 50% of these drivers had known that they had symptom s prior to their deaths.Frartliiann (1966) reported that of 86 cases of death at the wheel, 80 werei.due to heart failure.Coronary sclerotic heart disease was the most4frequent causof death.In a study (West et al. ,1968) of 1,026 drivers who died within 15 minutes-of their accidents'in California, 15% Lied of natural causes at the wheel.Of these 155 drivers, 94 %© died of heart,' disease--the primary cause was arteriosclerosis (86%), with rheumatic heart disease accounting for 5%.Baker and Spitz (1970) found in an investigation of 591 collisions involving fatalities to drivers or pedestrians that none of the collisions were related to natural causes.. Post-mortems were performed_on 102 driver deaths in Australia (Has sack, 1974).Eleven died of natural causes, and all were related to heart problems.In five cases, the drivers were able to stop the .car and:avoid being in an acident before they died.In the others, only one case resulted in an accident with another vehicle. Of 47 drivers dying of natural causes at the Wheel, 87% died of heart disease (DiMaio, 1969). -This was due priMarily to occlusive coronary arteriosclerosis.Twenty of these drivers knew they hid heart disease.In Sweden (1967), Voight reported that most people dying of natural causes while driving died 8.f arteriosclerotic cardiac heart disease.In a study of 1, 348 instances of death due to coronary heart. disease for people under 65 years of age, Myer- berg and Davis (1964) found that 71 diced while drivin There a'reudie which discu ss9 the p oblems associatedwith pacemakers and driving.Edliag (1969) found that of 52 pacemaker patients,with driver licenses, 26 drove a car, and 14.of thesedrove at least five times a week.Three needed a driver's license to pursuetheir occupations.Of those not driving, several had been recomrneindednot to drive by a physician. No patients reported accidents associated withthe pacemaker. Sowton (1972) reported that of 516 individuals withpacemakers in Great Britain, 39 drove. Of these 39, only one reported an accident; and this accident wasunrelated to the pacemaker.None of the 516 persons reported, suffering fromsudden attacks of giddiness or fainting.Heinz et, al. (1969), in-the study Of the drivingbehavior of 27 cardiac Pacemaker patients,fOund that they decreased their driving exposure 36% after pacemaker installation.In this German study, the patients reported five minor accidents in the yearfollowing implantation.There were also some problemsassociated with electromagnetic interferences with the pacemakers due to certain auto ignition systems.Crancer and O'Neall (1970) cornpa.red.44 licensed Pacemaker drivers with twomatched groups of drivers, one group with heart disease and one groupOf non-restricted drivers.They found no significant difference 'between the groupsfor either _acciaeti. t`or violations. Raffle (1971) reported that people withcardiac pacemaler> shuld be to drive but should-not bepermitted todrive a vehicle with heavy goods for public service.Ra.nsford. (1972) said that people with pacemakers can drive one Month after their operation ifthey are seeing a physician once every three months.The Driver Licensing Guidelines for MedicalAdvisory Board (USDIIEW, 1969) and the Canadian MedicalAssociation (1974) were in general agreement with Ransford.

0. Sowton (1972) reported on the licensingpractices for people with cardiac pacemakers.In England,.Wales and Scotland there was confusion withdiffer- 'ent liceriSing authorities adopting different views. Somepatients have their licenses revoked and some wereallowed to drive. In the Englishg-uidedines reported by Raffle (1971), pacemaker patientsasthe pacemakers become more reliable, will be allowed to drive private vehicles.The licensing situation in the U. S. diffdred from state to stat.e; generally there was no objection todriving with a pacemaker as long as the physician'scertificate said the pacemaker functions normally, and the patient 0-oritinuad undermedical supervisiorr (Sowton, 1972). In Australia, Hungary, Ireland,Japan; West Germany, Eas"t Germany,Po Belgium, Holland and France, pacemakerpatients were allowed to-drive. p vatvehicles. as long a:s they receive supportfrom their physicians.They usually not allowed to drive commercialvehicles. to/ Individual_: with pakoirnakers should-notdriveargo or passenger trans port vesicles (USDHEW; 1969).Brandaleone (1974) reported that theIndugtrial 0. Medical Association believed that a peirson with a pacemakershould not be per-, rnitted to drive a commercial vehicle, however, civilian drivers with pacemakers shellid be evaluated individually. While the non-professional driver had the choice of not driving when he clogs not feel well, professional drivers (taxi, truck, bus, etc. ) usually did not have this choice; therefore, persons with cardiac problems should not be liven- sed as professional drivers (Hartmann, 1965).Raffle (1958) reported that 26% of all bus drivers released from further work in a London bus company for medical reasons- were rejected because of cardiovascular disorders.Levey et al. (1963) reported an accident caused by the heart attack of a bus driver who had previously had an attack but who appeared to have-recovered.Trapnell and Goff (1963) reported that five out of 35 commercial drivers who had one heart attack had additional heart attacks, but none caused accidents.Norman (1960) reported th4cluring 1949-1959 the London Transport employed an average of 20,000 area, -' per year.During this time, there were 14 cases where drivers lost consciousness due to coronary infarction. There was not much information concerning the effect ugs used with coronary and circulatory diseases and driving behavior'.B daleone's (1958) opinion was that antihypertensive drugs can be dangerous towing because of their sedative and hypotensive effects.Dokert (1970) reported that anticoagulants seemed to have no effect on driving.Baroody (1970) reported that drugs usedf for the control of heart disease could be a problem. - There were several personal opMionsand committee recommendations for licensing of personS with cardiovascular disease.Somerville (1962) presented his opinion: persons suffering from fainting attacks, especially Stokes-Adams attacks, fainting from vaso-vagal attacks, aortic stenosis, and cailoticl'Sinus sensitivity should not be allowed to drive.In uncomplicated cases of angina or coronary thrombosis, persons should be allowed to drive private vehicles.

Irriric(1 962) made the following recorrndations for not allowing driving in cardiac cases when: here ias doubt of fitness to drive. . P- "Electrocardiographic changes persisted er infarction. There was recurring angina pectoris. There was aortic regurgitation. There was C- steno

Hypertensi as complicated by other conditions. I Balka.nyi (1971) reported an expert's viewpoint from-West Germany. People with, carotid ,sinus hypotention could drive but they should'use side rors.. Severe hypertension was a problem indriving because of the pot for syncope.People with angincould drive.since they generally have time to prevent accidents if they hai.r_ an acute heart attack. Ransford (1972) presentecanother opinion from Canada. He reported that congenital heart defects were a problem indriVing.if there are resultant performance deficiencies.People who have mild or irilrequent angina could be allowed to drive.If a person has angina at rest or if it was provoked by the effort required-to maneuver a vehicle, he should not be licensed. Hyperten- as only,aproblem if there were complications. There were a ntirriber of guides to the licensing of people with cardi5z, vascular and circulatory handicaps (Nova Scotia Medical Society, 1965;USDHEV(, 1969: American Medical Association, ,,1959; Raffle, 1971; Quebec Ministry of Transport, .1973; Canadian Medical Association).They represented considerable attempts to suggest the appropriaterrCis of licensing of anindividual with- a very complex disease. .Because of theWel-Laical Conte-nt of these guides, ab- stracting them might prevent the communication of much cplevant information. As a necessity, therefore, the pertinent sections of four guides are presented in Appendix A. Hartmann (1965 and 1971) reported that the new guidelines in. Switzer land excluded from driving only those with severe cardiacproblems, serious vascular problems and severe blood pressure problems.The Industrial Medi- cal Association (1960 made the point that in evaluating a person for com.rner- c-1 driving, it was necessary also to consider whether he was capable of doing the work associated with his driving. The Uniform Vehicle Code stated that a person who has been suffering from a physic l disability and who has not been restored to competency maybe disqualified .,:,-_.fpm'ro having a driver's license.It also statedithat When the commis sion had good cause to believe t at a person with a physical disability could not operate a motor vehicle safely-, -_his person could be disqualified from leaving a license.Forty-one states haveq' statutes comparable with these statements (Na- tional Committee on Uniform Traffic Laws and Ordinan'ces,197 and updated to 1975). There was'a legal precedent coneerni g cardiovascular dis e and driving (Arnerj,can Taw Reports, 1971).In a 15 case, the suspension of a woman's license was sustained; she suffered fro -arteriosclerosis and h tension as well as a stroke which left her left leg and arm partly pa.ralyze ,PubliC safety prevailed over her private right to drive. 10. Musculoskele andica s gkiscussions, of musculoskelefa.1 problems often included the related coordination problems associated with brain damage. A partial list of the conditions treated-in this section includes; amputees, poliomyelitis, paraplegia,\ ,herniplegia, spinal cord 'disorders; muscula.r,_dystrophy, Multiple scleros,is, spina bifida,congenital deformity, and arthritis. A number of articles (Frieden et al., 1969; 11Lateur and Lehxnansi,1 1969; Rehabilitation Record, 1972) discussed cases Of persons with severe hysical disability (e. g. , hernicorporectorny, were quadriplegia) who have been le to learn to drive and apparently to drive safely,The indirect reporting of similar experience was /seen in descriptions of sircial driver education pFograrns. This ranged froM simple reporting of successful-(licensed) driver education graduates (Berner, -1968; Match and Miller, 1969; Mathias, 197°2; Steensrna, 1975) to reports ofedriver licenstire success or failure for more defined mus- culoskeleta.1 diagnostic categories (e. g. ,orthopaedic, -cerebral palsy, delicate- ,. , Reynolds, 1968; traumatic paraplegic /quadriplegia, post-polio paraplegia/quad- riplegiae spina bifida, osteogenesis--Urie, 1975).An-acknowledged expert in the field, Jiki Sipajlo (1975), reported a large number of severe quadriplegic' and hemiplegic clients who, with intensive individual instruction, were able to obtain New York State driver's licenses arldrive in New Yprk City. 'Unior)e-- tunately, no follow-up data on the driving behav=ior of persons from _these.r.o- grarn,s'were available. It is difficult to obtain such information because' of, the '=.' expenSe involved in reaching a significant sample after several years ,driving exposure. There have been a number of empirical studies.Ina survey selected physically handicapped drivers, Mach (1971), in West Germandeter- mined that .)5_ were able to drive safely with only appropriate changes in the au- -tornobile.-- Using a..-qiintilatoe and 45 college-age subjects, Johnson and Lauer (1937) tested an induced driving handicap, that of using only one arm.It was found. that "errors" we-re not related to one-handed driving. was found that a person using one arm drives about 85 slower.The authors suggested that this' was compensatory behavior because they found little loss in Manipulative efficiency due to the use of one arm only.In Denmark, Bogh. and Poulsen (as seer

-69- in'600d 19:74) n A isasbled(poliomAtitis and othe bras da keltal handicaps) and normal veinent of foot froin ateelera- sons bthree p-s chom 1 to brake; inoverfientrof h hand-unit brake; operation of a graphic key). an often cited. sirnilator studyMcFarland et al. (1968) studied the physical components. of s.teering and brakingfor 20 non-impaired norr4corn- mercial d.rivery, 2 ,non-impairedcommercial drivers, and 60 arnputee McFarland report4 that there was no evidencefrom the study that orthopaedically impaire persons (unilateral handicap)who wereabictrispass con- -ventional driver licensing-road tests,performed any more poorly on tracking or braking tasks than didthe other participants in the study.}le did mention that the experimental task conditions weresimple isubjects.were notretfuLied to time-share their extremitiesbetween two ta,sks)., He also noted that ahigh percentage of theseamputees had unrest)).d 'emotional probleips and, there l. fore, suggested that psychologicalscre'ening re licensing might beimPor- ant- arge but not well controlledstudy (age, sex-,-, and exposure com- (1968) investigated the accIdentand,vid plicat neer and McMurray 2 L. tion shington State medically restrictedrivers% ouncl th4t the gro stablized physical handidaps- ( g. aralysis, es, and certain visual defects) hadStatistically higher accident ewhat controlled investigation, 'the Washington,D.C. DMV ,f d, randomly selected group of 50 orthopaedicallyhandica an ac dent rate nogrea14ter than thc accident rate forthe avera D.C. driver. Ysancler (I 9'66 ) studied 494 disableddrivers, the'rnajri Leh 0 I had a loss of function in the legs usually-,thieto either amputation dpoliomye-1/ litis.Using a control group matched for sex, ageand license-h.olding'period but With shorter expos ire -to traffic,' hefound that thedisabled drivers, as a' group, had fewer,accidents.He did suggest, however, thatdisabled driVers with a loss °LI-unction on the right sidehad a somewhat greater percentagof accidents than hid other handicappeddrivers within the group. Dreyer in a study: for the State of CaliforniaDMV, studied the accident -rates of694 handicapped drivers (drivers with license restrictionsrequirin hand controls, steering knobs, and artificial legs).In a comparison witha ra dornlyselected group of 1, Z37 normaldrivers, who werel-nore likely to be male,single and older, he found that the handicapped grouphad a similar involvement in total accidents and a lesser number of convictionsthan did the normal driver.Dreyer

-70- did n.ot, howeve,have any,con rol fo,r,exposilre.In 1974, Hymen_ stirvexe the ,663 hand--cbntrol drivers in Washingtbh State.She found no differences ;in accident on violation rates b-ettiveen.hand-control or normal drivers. Numerous guides offer 4icensing ex, ation guldelines for the handi-. capped group`under discussion (Nova Scotia COMMittee on 'Traffic c =idents 1965; American Medical Association, 1968; USDHEW, Public- Health Ser-rvicit, 1969; Hartmann, 1971; Waller, 1973; Quebec Department of Tranfport, 1973; Canadian Medical A ssocration, 1974; Koschlig--East Germany, 1974).The most recent Physician's Guide for Determining Driver Limitation wit! 1314:dished by the Committee on Medical Aspects ori Automotive Safety of the Americat Medical Association in 1968. hey noted that all prthopaedic impairments must be carefully evaluated on an individual basis.They stated that the clent must 'gene 'rally have sufficient strength to turn the stee;ring wheel, apply -the brakes, reach the controls either by mechanical attachments or `by 4134,6Priate prosthetic dylces.Specific infoimation was provided for five body regions: rheid and neck,_ thoracic region ofthe spine, thf lUrnbar region of the spine, the upper extremities, and the lower extremities. They (AM.A, 1968) stated that even significant restfict 'in head and neck movement was compatible with-the safe operation of private vehicles,- because,me-: chical aids were ava Table which Could compensate for this type of impairment. Spec casesca whichraclycontraindicate driving are; .'-.. clients wearing neck casts or bra . . . severely'r-estrict moverneint and clients with spastic torticolhs. Clients with diSabling conditions of the thoracic region of the spine w generally adviseciadinst driving a commercial vehicle.Those with arth(ritis associated with Unusual or painful restrictions of motion or respiration excursions usually 'should .be advised not to drive.However, individual with the proper compensating devices could drive.Clients with'interscapular pdin causing restriction of motion in the shoulder joint and increased vulnerability to fatigue should be advised not to drive until they recover. Persons with severe cases ofcoliosis accompa.nieciy painful arthri-. tis should be advised not to drive.Persons wearing braces should be evaluated on their ability to manipulate a motor vehicle safely. *Those with extensionsun- der the arms_which could interfere with circulation are usually unable to drive safely. Persons with osteoporosis sh_ould be warned that they may need bucket- type seatingand other restraints. Patientswith myeloma of ribs and spine should also be advised to use_proper supports and restraints.

-71- According to this guide, the lurribar region of the spineshould be normal for drivers of comipercial vehicles, but lumbarabnormality does not sarily incapacitate an individual and precludesafe operation of a priv die.Persons with lumbar deformities, stiffness, andneuromuscular d from card to nerve root defects should restricttheir driving.1-10frever, persons with arthritis,osteoporosis, congenital anomalies, and s5oliosi drive with the aid of power steernig,, power brakes,and automatic trans ssiodn. Persons with herniated lumbar discs should notdrive while in severe pain. Normal functioning of the-upper_ extrernities-was recommended for d vers of passenger transport andcommercial vehicles.Persons with one g arm could operate a private e-vehiclethat has automatic transmission, power steering, and .a wheel button. A person with one arm and oneleg can drive but may require the balancing effects of properprostheses.The strength of the hands was of basic, importance, although prosthetic devices maybe accep table. Normal functioning of the lower extremities probably was necessary for drivers of commercial vehicles, but with good armsthe -absence of both legs may not.preverit the safe driving of a privatevehicle if proper prostheses and controls are used. This Guide also included a number of other disorders ordisease pro- essds under the topic of musculaskeletal sincethey impact on muscular con- trolor coordination.Those listed were: paralysis agitans, poliomyelitis, )hereditary chronic progressive chorea with mental deterioration,Multiple 1 rosis, hereditary sclerosis", syringoroyelia, musculardystrophy, cerebral y,t myasthenia gravis,turners of the brain and spinal cord, arnyotrophic lateral sclerosis, poq-traumatic syndromes, and intracranial suppurative processes which may affect muscularcontrol and coordination.The Committee then described fouificr spec disorder'ssor, which could cause problems: Cerebral palsy: Clients suffering from this diseaseshould be evaluated accordin.g to the degree of their spas cityproviding there are no severe neurological complications. Pseudohypertrophic progressive muscular dystrophy: Since this was a prodressive.disease, clients needed frequentevalu.- atiom. Rheumatoid arthritis:Clients_ may require adaptive devices in 'order to drive safely. avoidporidylitiaThese clients e limitation 4 on in entire spine a pteripheral jointq as 11 s a gene weakness rhay contra.insliege theix in general, the Committee mended that At was the, physicia' re,epenai., bilits to recorninencl that a client with a. pragrepsive disease ,discontinue driving when the :disability reaches a point wheve. drivingrna.y'becorne unsafe. In 1969, the Public Health Se nyice of the TJSDNEW suggested a pro- cedure for evaluating functional rnisculoskeletal performance. a.,lt 5 and the next section have resit taker l from their publication. Table 5. Soto of Function

I III 'Inger Cargo Private Periodic. Trans Transt Auto Reevaltic

yes ye no ye s no ividtral yes consideration

of the right lows r extremity and -both upper extre: ties-are wily called on. perform the.tgmks of driving.The testing of these riniscl based on two factors: the force of gravity and the resistance applied bye earnining physician to the muscle grotip being tested.' The dete rrnination of.lullso1strength should be base'd'on th tion oche the r thefstretigth is : Normal- -Goin leto range on gone vity 'vitlu full tan'ec._ Itiirx ran le power %vas Right ankle dorsi and 'gilt knee exiension.' drip- -both hands. Beth wrists -- extensien

Bothbcaws --exte rn iorn aid fleon. And at least good muscle ri flexion Of theright e.

GrouT B Muscle power cla the jointi: ht ankle dorsi and pla oflexion. or Right knee 'extens on.

dip flexf-TFA an&,ext s- h hands

fists e xteion and

, -exteisio r Fair muscle powe r any" one rao r is listed hi. Group A a. B..p- And poor orgeimrcle pveryin flexion of theight A A ctive flange of Lion -of Joints,

A lortg withhscigifdent motar pow a driver must have adequa ejOilltS_that are important ,to the safe oper t or c motor vehi- e variety ofode Is, make 5 and design years malce it impossible girlie on the de-gree of Joint _motion necessary for arans,ingle motor ve- hiol somecases;-a. driver' s_license .applicant r,;y compensate whim-I-tally welt for his condition,and be able to operate a motor,yehiCle*Safely.All eval ations' of this kind should be loased on. individual consideration hy- thee hysician and on the performance of the test. Amputat o Loss 'of a part or tl vhol al limb manot impair dri`- vm skills the private vehicle but main alp corn:me rcialve cle ith the evices available oday, the a. ripute e rny-7d-ri-vd; safely- in mosttrafficrtuat i on For cases brought- efore,rr:reclical ad y beads for reiriew,individual evalu- ,ation was req ar p,

t 'regulations fop,liicensg the phyStically handicapped z land. were sigested in l971,0 (a mann.). %r driving a. private automobile a pe ,son had to ba roinimmtai l 5c (5'1'') tall and have no malformations of the chest or spine which would c?nsiderablyrrainish bfeathing or mobility.With resp.it to e,ctremities, sort we no Ariutilation,s :p.ffening or paraly- sill which cannot be .co cific devices in the vehicle. In his ted various. chronic or recurring .conditions ma.y coordinat. atrial d.rivinmobility.lie felt that persons who ha e stable. conditions putations reqred evaluation by means04,...,,pr-ad ical.drivi.ngtest cir Far thosellhandips where c- ti'onal disability may be epasoclic-,- here.comme d annual episod-become more.and rre frequ- erta, driv' mUst no Waller,as sezke rally, of tlopi iothat mediCal conditiOns A accide e 1973, the Quebec Department ofTransport published a_licensuis iguidelines- required that peraonswith disorders of themusculoskele-, tal st 'enlist prove to -ttie motorvehicle bureau. examiner that they werre capable of "g all the,controlmechanisms of the motor vehicle for which they Addition. 11.1,y, they mustprove,that t}iey hays , -.- are driver's license., functional eirbti ricicifreedom of Movement to ensure their nor .Those needgig a prothesis orbrace nlust shew that they are capableoftdri anautordiiileiihout difficulty.' Thf followihirferrnation' has beenstu:nrria."'` zed-frail:). that GUide. ''..

cal Vert -e AppScants suffering from, a trauxna,tic or i ory lesion vertebrae shoUld riot drive an autiartiobile until cured.Pain or &is- 1 ., A- On the should. not prevent thedrivip.g of a privatevehiele d equipped withran. exterior rearview niircer. weighing less than,'0 po --..,. uf 1,:,.:, Such applic hOUid 11 apublicve ..t

Ve.

o ba.v altoirri4tior of the dorsalVrtehiirae e vertebra* shouldnot vc public .16 who caniot Move without ray drive 'a hide Per@Ors t vihosernoVe re ndt. excessivel -pair private vehicle. lithose curb weight-does tot4ceed 6,000 e sons.- ring from sei:re4) pain in thinterscapular region overnentS should not- drivean o oe, Benign h restricted shoul ea o moderatescoliosis ordiriiiily wouldnot,pwevent a p on ex.ceive fatigue, persons having pronouncedscoliosis causing severe pa.ip o , should not -drive. Persons wearing a pla ter -of7paris set may, drive a private cie whose rnadcirman c pounds. ns having a shoulder braceand Safety be result of a' sudden stop. Lumba. r Ve rte dividuals suffering fion-i lumba al,foions, ess, neurornus r problems causedby ricu1r pr'siOn ive vehicles with restrictions ba.sed,on the ty nt e muscular strength of the legs. '-

'ITI:1 drivel a puc 'vehip e witito* danger, 'the applicant$t be

able to use the aritis-freely,in,a &- tree. manner.The ti.vo hands must b able, to grapp the steering eI with enough 'Strength. to maintain balance and control in a clden .0_ efore, te/applicant, must have a- sufficienyium- ber of fin d- e a .Stron -grip., Persdns having functional hand disordersmastekt its to_g p to s ring wheel firmly Persona-. --'one arm can usually drive a. private "vehic whose 'curb we4fi do e .6, 000' pounds4 if they alwaysT have. complete Control of the stberini el, aid rust tot let go of the wheel to control: other mecilb-nsms. =

or se mOverrients were uniteor mdse muscular strength _spay or.,coordinatronere ., ay drivea plopprly equipped prirate vehicle with -,

restrictions.Persbns,who suffered froth -aaraplegia or papa'rerais often re red:.,. .._,-- , , 'V special equipment' ih. orde r o ctrive ,,siafely. -4 The folwing te, aken from the_Qiiebectilde, the variaus types of licenses whic may be 'obtained depending on the and:degree of amputation - or arbkylosis.

The re Stritc,--tions 8 %Jotable ply only to persons whose amputation recent or tho-se, reluestinglicenfoi- the firsetime. _Persons whose a pitations w_ e're notr,-r....ee'ent and' litt,cf beccre accustomed-to drtving inAnia! which ensatek for their handicap would n4 be sub'ect. A. to the restrict and ap- lying 6 having recently dergone.,, a.rnputa.tions. in 104, Lthe rrirri tt e on Erne geny,Se ;wires, of the Canadian Medical, a&ociation prepared a ode for,,physiCN They n d in their introduction tliat)he re little scio 'c evidence cap u eto assess the degree- of pairm o dqving tita t results from anspe cific s 1.1klitycTheir stall- da were intended onlyas a common sense placement of restrier .d, 'in upon ivers.The g suggested n the phypicia. aSes e phy stati Alt \\... , . Category assof Handicap Resttic o license: 1L vehicle -, la Arm cludfng 1b ow public , brearm iivehicles and .- Tive Private H-Vehiclemaximum curb wei h fingers vehicles 6000 lbs. ,T -Automatictransmiion . K -Powersteering or-oinne ob on steeT-Engwheel , M-Foot controlledwipers

. amputation tour 1.. cluding

tobuses . 1-2 No restrictionswhere-prehensio cies is firm. Otherwise, considered as havinonly one hand. Prehensionis sidere if the perso9,has at least, ,phalanx qkththumb e rst or secondphnf the fingers.

--- 7-- 1 on or tl s . Eib w, PublicorNo restrictionif th - -tea other ankylosisfalls betwe ction.'. vehi 135°, if thereis ere . is supidationan and , wrist arenorm_ 1-2 E ccludir If the limitationor 1 less than450 or gre.-, 'c. , c E,1 v ic 135°, thelicense -Will pe grant d after a studyof the co teats o report andthe follows r icy; -'tions pillusually be made.: Pri(rate H- Vehiclemaximum-curb w &alleles 6000 lbs. . oversteering or 11 ob. , n steeringwhe,e l . ( 1'rivat lVlucualr'strength and su t movementof the f?re4 ale t be taken intoconsideration. Tabi; 6.Physical Handicaps

y of lass o Handica vehic Cation Hip Thigh Knee Priva H -Ve cle xni n curb vehic] 600lbs. J- AutomaticArans on Q -Manual dimmer magic eye R Acce1earar on le new am ee -rig

Hip Knee gRestricti an& will depend on the angle of ank ykOsisor:ltlie degree Qf limitation of move ment asre garde the Fat egory and1.Isei of license requested.

H- Vehicle 'curb wei 6000 -J- Auto ssion ** Q-Aelantel dirtinier light switch rnagic.eye ** R-Accelerator on left si4e (for .Trw amputee- right leg) If the' pued at the the p,,--trient i,s considered a tbi. arepute e. the amputati9is ti' to he is' considered leg a.i.nptxte

putatioh Al the ankle, amputan Foot veb± le arsal or riaetatirsal Toe s repl.acd hya prosthesis, and amputat% 0-1 the' toes will not usually re quitn restrictions on a driv licens r in a,stcZa.nge of cater o 'ecepx when dg4d aiky following,a 6ricer "ceni, 5 c s Type # a eur; profthe sis. In gene y felhauthe ability to movements of the-head and we'reeaa conditions can Use,poor.coord nation or elecon group of diseases were oliomyelitis, Parkin disease, rebral palsy,lauscular dystmphy, myastheni ravis, 1 a.d spinal cord, org&nic brain damage followin a hea In the early states o somc'of these conditions no needed and if the` disorder '../anot progressive only one exaimna quired.However; if the disease.wds progressive, the Applicant d be examined at regplag intervals and driving discontinued when th4 disabili reached a point that rdadf it unsafe.In some of these Conditions, hove asloveilni of *e th6b.ght fatocesses is liable to lead to loss' of consciousness,.* the appliCAnt shotEtd not -dri#e%nY Moto& vehicle. 4-? Occasionally,, an applicant with a mild lips of muscle control might `requi echanical anliances added to his car.The driving examiner knows the a .noes tha wei ild. be apprpved and can give adviee on Whatquipm ent was, le and ere it could be pur!chazed.ifflien an assistive devicZ has

, ed, th,p Applicant mist satisfy the examiner that he can dive Safely. been t.,

T1 iliotir vehicke driver with othermusculoskeletal disabilitie must ed inriris of ifis 4-a.bi ity -to pewforin-automobile control move ienta accurat, ely, re e the e Canadian Medical A ssociation rfoted=3 me c*sesthIs 14 od, of assesseht was, through,a road test con- uc.td by' theA dever, ammo r he Gorrimit ee'S other guidelines far di.sabili- es of the. limbswerenearly .in a rementiIii thoSe of-the Quebec Medical Asso- ion.- 44 se conditionsthe interaction' of -the rapeu-- 44. Nkt,i,druksi must' al since these caul e ce or degrade' clriviiyg ability. ,Most guidel not comment othe impact of therapeutie drugs safe, automdbile d ri:g a ugh-they haV a separatetionon drugs hi(ch m y affetteriving. lea le did mention th g of,one uscie_laxant ttaris dol). lvi er962) four' at 700 fng. (cos ided normal rapeutic dosage) taken over a odweek p od had no effect on ait imulator driving task. Dokert (070) states that the of muscle relaxaqt was prpbably minimal.eince theywere generally use hospi --- Alkbut ten statehad statute hickei red the G Mote ,..7Ve'cies either issue'a,ive r S driVer's license of, any person thought by reason ofphytrical or mental disL ability not able operate a motor vehicle- safe'ly(Natio-Aar Conuni.ttee on Uni- rm.Traffic Laws and Ordinances, 1975).In 1972,tanu Less surveyed sta.tes in an attempt to summarize eke policies and p es which were in testing and licensingthe.a disabled drivv.They d find much uni- ity and at times theyfolatic# confusing, non -directive, and misleading regu- org`s. They felt that the seneral trend was to license terson with table ditions long as he drove with the special equipment. zed during troad Pers k s waferinglfrom unstable conditions were more likely to incen- sed but with e pyisions for:restricted driving.This aeems to borne out by the treatment of stable and utable handicaps in the legalslit Most legal cases dealt with unstable rritieale or coordinationproblemswhe u °logical coznplicati6rismay spasthodically interfere with saf driving.

1963 (American Law Repo 1971), the cores reversed the license suspens of a person suffering fromultiple sclerosis. ,Un.disputeamedical to oily was introduced to the effectat this person's spastic paraplegia, with co aralysis of thelower extremies, would not prevent him from safely opera.tiiig a nd ebtOrolllid,vehicle. Adionally, he could overcor* double vision (due to e scleros,i.$) by, siniy closing eneeye..Ln another case in 1955 (Americ keports,, 1971),`. konhaving had a Istroke and suffering frorr.perte lion, arterial changes# and limited motion ofthe left arm and leg was not allowed the continued use`of her automobile. Persons with rnusculoikeletal handicaps could havetproblem-e with strength and motion, coordination, perception and cognition.All of these could' ion. i. impact ttrive-r, e Many programs utilized pre-eclucatimassesSmentlo'1W screen stud programs or to place therrwithiniprograrhs.,:,'This a: ess- ment was oft a team of specialists. (Hoar:Th., 1969;Brown, '1975 ee4044. clay 19 975) \and could include an intenste interview, ,the 'us chologi and psye ysical.tests, and. an intensive medical examination. Mo- imp meant f r this efoup be) a simple test to deteine-the easeo- with which a client car nteand le&ye a vehicle (Hofkosh, &the.

die rrnif na.tion'of whether the client has suffe o affect his Nfislial, perceptual, or/ cogig- tiveb either by, using palper andefici.1. tests (HDf- kosh eal. 1970or s simulation.Brown (1975) stated that a sixnulator, wassect y phy and Occupational therapi A° evalltga- rcep- teal and otoskills 1975) usedja s n.tirne, startle refl:x, grip st Lrant arm 'ng ability to press own and pull back- rld-controls (10 lb. nine=and .the ability n the steering we1 360 gfeei.After a p ram'of instruc on was begun, continual a.sses me t' required- to.- f6cus on invil needs. y curricula were adaptations xisting curricula for normal studentsReynolds (los) studied the practicability of teaching.., automobile,- driving physically disabled high school students.His curriculum was ,it, very similar to the regular driver training programused in Los Angeles city schoOls-Generally, more time was required to teach these students than was normally used fcevegular students.Three groups of students were taught: orthopaedic (loss, or loss ofuse, .of one or rnor, extremity or handicap involving the spine), cerebrldpalsy (limited to severe orthopaedic invo ment), and delicate (epilepsy, he'art disease, as hemo- philia).Success obtaining licenses was greatest foir. the orthoedic gratis) and least fair the cerebral palsied groups.Tke greatest blem encountered in the teaching. process was the ieoiation`ofperceptu.1difficulties. e-mechanical skills required fon, iehicie operation were reported to be much lea probleen. . s Modes of instruction often included the use of simulators (- 1ori.o, 1971; .Goble, 1975),Long (1974) discussed the Highland View HosP1 programs in which simulator performancewits used to screen for ent -etinto the behind-the-wheel phase of instruction.Those;,,who complete phase one successfully were likely to be successful in obtai 'rig their driver's license. .Ogle s (Hofk osh 1969) felt that simulators Yy.e, ref limited use due to their ....lackf kinesthetic sensation and limitedperiphe al vision input. Ln -ca.r instruction w often pnceded by -tests for .visual or percep- ual deficits.4 Sipajlo (1969) described, go vie basic maneuvers ofbehind-the wheelevaluation.11-a se were the critical exercises ofchanging. direction clockwise to counterclockwise, changing pattern from circles to figure Sipajlo claspi- _eghand chaxiging direction while ia figure. t.,eight pattern. client per?ormance as: withori cultylifteldifficulty, and obvious culty.Clients who did not experi ayd--rNficultywere then evaluated proper ass ive d s and rec ilded foi'complete trail:114g.Those who experi-nc cl o Obvious difficulty were\ usually trainin` better: visua (lures.If iko progress was noted by thend of the evaluation,/(hey, ot to:drive pending re-examination lly schedule_ d within on ograrns used similar p:socedures sey, 1975).

actorswere a ofhaving. a siinifiscant pact on driv. nd (1968) note sychological .-xaminations of a lik_y to exhibit ch ondepression.2.ardach (1969) withauma ic injur 6u1d not relearn to drive un- their'rew bbdy irnag 1971, T3.rdach studied 31 Pa- as d cult by driving ,inructors.D" gnostically, the patients demonstrated varioUs kinds cif ne IA es and char_ r disorders'. Bardsich noted that these problems seernegenerally le,ss sa ient in brain- damaged group (heritiplegics) than in OA norrain- damaged roup. 'Kirk (1972) also noted blems of malad ustea behavior in outrini tg problems asso- exceptional c

As been stated in a p (Driving Task) very little is lolown about ieZ4udito requirements" ry 16r safe driv"_g.Iii 1973 Henderson and Burgudied the auditory requirerne ts, for truckd bus driv7 ing.They found n ne which were directly related tbehind-the-eel per7 forman.ce. 1.974 they studied the auditory requireeats necessary fok the Safe driving, f a private automobile.Only One critic I tam had and ory-requirements. y felt that this may have been moire ction of the anal cal procedures used to isolate taskp-than an accurate assessment of audition's role in safe driving..n a recent simulator study, however, McLane and Wier- wile (1975) found thatVie deletion of a YelOcity-dependent audifol" ngine - . noise) did appear to contribute to a deteriuration in4 uggeited Mea.re ofiliafe _ . driving.In general, Henderson and Buit (1974) State, that theborripo exits of interlbr and eXterior noise more than likely cOrnbined o minimize thernet, of auditoryDes on driving.

Ep =t opinion usually agreed invor of he deaf drer ( n,904 To 1969 ear,1975) although Ghee ham(1971)felt that at leagt irl--SOuth Africa thee ely to bei lverl in an a-dent with -se u- consequences-- Judge Sherman e r -had c' ardentrec rdof diiVers manyfife s. iutai he"despribed a studno ctrols porn -' par-__g 100 deaf Co veri-s out 100 he driers. The deaf driNIrs had lath ions anu es.Fidever stated that tlie, dea drivers' abi ent rate (no- .stracitin y e em to be_e better dries

Sornewhamore controlled vey$ orstudied have been-reported by Royal° 1976),Henderson and Bur(1973), and the Washington,-:D C., partmen Mot Vehicles (1973). NI.R:odhouse described a surNkeycoo ueted.9, among deaf d in New Zealand. -reported-accident data.ovtrieJive year period w licited, from 2 ve rs.The younger ,drivelv (unde 50-years bid) ha vier accident he-hatioha.1 ayerage while the older- drivers (over 50ars. old) had a higher ident rate.He'rderson and Bur 'studied accident ordsLof 250 truck and drivers (with different degrees of -tiea ring los s) , found that the greater the person's hearing loss the lov:rer accidentratepartmnt,. and the &ccidentrate $cxf edge t group ye-rage d r 46if_or-:'d

68 hein rio ; D. study.Cia,rn- e automobile and vio .on a deaf eus geral populatia* d that deaf drivers hadLegg thah one...thtrd the number of accidents ne-fourth the umber o: 'ova studies were d of o Departnient Motor Veb4cles.In 1963, Coppin orted that a s ample of ded vers had 1.78 times as many accide 6itimea as many cOnVictiOns as did the n-deaf,In this study, howe deaf differed from the non-deaf on a num- r of vaxiiiab)les: mileage, oe'pat on andx. In Ig64 L-svp, large 'samples of deaf and non-deaf were matched on five variables. age,annuahnileage, accupa 'on, sex and area of residence.It' was found t deaf females did not si W.- iLcantly if non -deaf' females on either,-ac F-i:.dor violation.porn, The de f male ple had gn accdent rate 1.8- tunes her than the accident rate of the non- ea male sample. __With regard tfko. st C- , the rnales did not

sign]. icantldiffer from each otheff .r Thee ivers selec 4 for comparison had come from, the Los An eles an rand areas.They had demonstrated a higher accident rate than had drivers from other geographical areas of the state.

, .The recemrnendat.. t --ns g.., aring often htairiintroductory- rema.r. i.th'akthea n compenSate for their handicaps by increased visual-vigilan, cal ,Associ- `' ationi 1968; Canadian Medi*t A sad tiOni- 1: citia ComVttee fficocAccidents (19661' ended that paired 'private bile drillers use an view mi as disciuxfyin ofpasie.nge vehicle scarify tor the a- e rcial. or private 1,re except it e person wa of according to the, CAM.

--teSM;fican sbciation dphy ' it deafne handicap opars.tion of auto e, bu4 ttit viatu ated for.a 1. However, it sdaid ttia, plete dilifner 119,1 1.:Opt g passenger transports d oche r c mime rc t1On of.taasi3engervii- le; e USDHEIAr-Pue Health Se ce t 1969) define as the inability of a subject td-pass a vo w,iecognition to -rectly identify- four out o numerals spolcen in each ea he 6 standing 2-feet behinci,the patient), or any equivalent test slec ed as appropri- ateXyAlie xriedicakadvisory board.It suggested that sucindividuals. whpse cases have been reard, tote advisory board.be grow as follows: Group A - -Hard of hearing from before the age of 15 ye

Group 13- hard Of hearing after 15 years of age atd ha aware of defici:y for, more than 4 years; Group C--BecAxnp hard of learing after 15. years Of age nd e ofdeicicietk.y ,for less` than 4years..

In theabSdence other adv'erse factorsindividuals roll th categ9ries may be recommended fOr a private passenger vehicle"licen these res,trictio Those in Cups A-,'13 and ci should drive only in quipped w o side mirrors in addition to the inside rearview ITU dse in Group i Ion-to the above .requi d have ton. y compl ted a couriLe degned fo -deaf driver.

ThelA We re...0 y few deaf peole-'e iriployed as driver --s nspoV' or passeliger rt vehicles.Fi.enCa', 'there was a scarcity data which ccrald elther7rsupport or refute the y of the deaf individ to such Vehicles Safely,1:roiri,,the medical int,he- 1.1SbliE deem it log to recommend liee.n eStric-; g sted for Crc C for drive s of priva senger vecles., advisoryhoardwould ne, chideems;sting s at- laws and 'regulation's this matter and might . idetheth passibility license. limitations connection with eith pasbenger. transport mvolv.inspec1*-1-ha.zard51 ., The/Sw i eGov ent legal regulation s covering h ear in au ornObile driving were d,sci.ssed by_lia.rtrnann (1971).!, r vate vehicles thee.rson must be capable of hearing nor- meters' (26 feet) without aid:'' Commtdrciahand driverse ed two- side'll convey liktional -hearing at 3 me e.s (10feet) without aid; .one-sided. deafness `these drivers mui'%t have s. 6 meter (20 feet) conversational hearing abilitn their good ear without aid. .-,... de some. specific reco ions- to-evaluate hearing with ylkg hearing les$ 11.4 cfriet.bbth ears could usually e-4-pleasure, or cotn- Uridge .dtrigeres if the vehicle wasequipped with a "roar- va rcial vehicle without _ w rror on the side, 4thl pairment.Those, making application for a is license witIve,:a hearing difficulty would require a medical ort With audiograr IA0 0. percentage of discrindinationrbr each -ear. ever, publicvehicles ikt driver must speak to the passengers required more stringent rl tionsp Minimum decibelClearbig levels as Jett rs4ried by the, Americanaat Stindard Institute have been employed,The action of speaking voltpassengers in noisy vehiclea.,Couldwell be da4- e ous.On the other hared, if thedrive r%=does not:have to'spfak with.passen- the decibel levels have beenioinewhat,relaged, ..Waller (1973). noted Qoppiri and Pecks 190 study andsugg6sted ths,t with sever,e'hearing-Joss (greaterthan 50 decibels at 2,000 hertz in ear after correction)slia1d be !permitted to drive usingspeciai mirro only during the d,aytiine

The ney Services ofthe Ca na di a Medical As .so- 1974rst 6 wIth a ivk of .hearing acuity- usually could corn-- their halid required an aucdiogram'for all clasSe-sof, ve -than a :irie n applicant for6, licegie should be refer tone audiog.rarb y.hearing loss is suspected,*

The c/o ItFiat passenger trangpo'andcommercial -vehi 1 ator have ,a significant heal-ing koss:A lts.of rridre ..}1 ona pure than 4 cibels on scale at 500; 1,_000 and 2,000 terieau eter in either ear was significantif thfls, applica- rif,wasAlri.Ging a passenge ar.rying Vehi.Q1e.A 1pss of more than 40 decibels in was gnificant efa-pplicant was dr4ing a. heavier comrrercial transpo rt-h The Co e alsu§trated that a- hearing aid may e of seine value in ope ration private vehicle,_but wasgene,eally of'l ttle help in 'improving hearing 0 've noisy passenger transport orcommercial vehi-

All but ten' e UnitedStates, tutes whirr impacted on g cif.persons w heajing less.l ollowing, the *general rulethat physically competent to elnkive atar,\, and b) bile drive F ,, a) t rj11, xp riencegCorpus_Juris Sectindurn., 1975), have inte d "re uisite s.kiLl and experience"to'rnean "Sada- This means that the ot).ra tr a _son.able safety.

A not required to possess the highest degree-of skill.The escases have determined that thehearing impaired driver canuie his .;...otU'r faculties to'Cffset disability and, therefore, coniorm'to the atandard ofa-rr'e required 1)0.11 dri-

ve-r s A 1116 The greatest problem in teaching the deaf was, o cburse, the ?corn-- unication..asPect.The scv.erity of this problem wasrelated both to=the degree: of hearing loss (Kirk, 1972) and toithel age at which the perionlirst became paired.The earlier the loss and the later, formal education began, 6:i_more difficult all conununthation.becomest -ft

,.,.., A number ;of driver= education programs taught the =deaf driver (Tog; 1969; Cunninghani, x1970; Layton, 1974, Mis-ner-, 1975, Champagne, 1975).Modi fications to a normal curriculum usually include additIonal yis-ualS.(oftenTc tionedCunningham,-1970) for visually commtinVating to the 'student while li driving, additional dashboard lighting (Champagne, ixs),' and sonietiines .Spec in-ear devices. A number of programi relied on simulators. , far practice in o to minimize hazardous' first timeWheel behind-the'Generally, experiences. Geally, the deaf were noted as being especially alertehind tie wheel. The psYchological aspects of hearnig loss.as they related'both o Counseling and eduOation have.been.discussed by Le? ine -(Garrett and Levine, 1972) A very supportiye learning environment was req fired f6r4-- the pe re,ons who stiffer either froin Prelin.nal hearj.ng.1 loss or from progressive liearing loss.

12Repiratory Conditions. Where is practically no objettiv; research information concerning the -.

effect of respiratory Conditions and'driv. ng1 perforrnance, Norman (1960): re= ported two bus drivers in ten years who lost consciousness,during work.The" onewhohadwhooping cough also lad an- adcident with another Vehicle; the- othe r had lobar pneumonia. _ There are, however, several opinions about the licensing of peoide with respiratory conditions.Wallner, (19731 and the Canadian Medical Asso- tiation (1974) recommended that a pe.rson who climbs ore= flight of stairs ,-ox walks on a level surface for 100 feet and has dyn.pnea or cor PuLinonale should not be allowed to drive.The Swiss, according to Hartmann (1971) will not permit torive if their driving performance is diminished because of. breathing difficulties. A .de:_ erieral respiratory fu .ction was presented by USDMW- (1969):. o driving ca.vised by ventilatory deficiency. may b4-' rowed is' foll . . Grbu ys are us y normal but may Shaky healed, or -1 cifthe chest. \ Dysphea, if it occurs, is consistent and degree 61 physidal exkrtion.V4lues! ob-__ tai ne o-of the ventilatory function test are tic) ess t _predicted normal values for pa ent's age,. sex, and gases are usually within. the n range.'e

Croup a 6 -ram normal or,.a.bnorinal." Dyspnea does not .occur;af aid usgally doss riot Occur-during the peTf9rmance of usual gal bfi s; iv'fives ?;7'hg s-ub jst cat keep a-nor m:al paceiit personsr Of e age _.,przid_brtay build onlevel:.gr9undWithoilt b eathlessne notonhittsor stairs." 'Valdes' obtained \from at leasttWO-ref. tilatOry futritition tests are in,the range of 70to. 85 percent ofili&p,t94ctickn rl_values.Blood gases usviilly-e axle normal iit the `o part al piesbure pre on a random

sample= of 'arterial 'or_-130 a be diminkied.to 75 g` I=:.

nrctu.p C -.Chas Xiotmal but tesuall . net. Dysp-_-1 nea does not occui re,,pt.but is present during rice 'of a -r P uslaal daily activitie m_vicdi can walk one. at his -own pace without dyspne4 ,unabl a keep up with-his pee ',...Values of at least tvio ventilatory function feats are in the range-o n5 to 70 percent of the predicted normal values.. , The blood gases-ake abnormal with the partial pressure:4 of arterial oxygen no- 70 mm. Hg. Group -chest X-rays are usually abnormal. yspneaoccurs Climbing one flight of stairs,- Walking 100 yards on,the bg; even at rentsValues' obtained from af least two Ventilatory fuiic Lion testsare below 55 percent of the predicted.nornormsvalue, partial pressure of arterial oxygen is less than 65,-nam..- Hg:

- 87 pt able Le yo of Re5pira o_ry Funaion 8 Drive *r.ensure ,

II., TILT I -.- "

IDrGargo iv4te Limited grOup Pass -11. Trans-poi ';-.Ttans ort'-,, Auto- - Ree 1 n------License . ,

y ,1 S no - . . . dividual rc, n tion -.yes , yes - no' ,yes cs yes'

o oth the Canadian /4 di-cal Assoc ; 974) and the2 Quebec Ministry of Trans recomrn tided that peoewith -infectioustl]t-i.oulosii ahould,not _ - drive`'{ reta s carrying p:a.'trig e .TheSwis s agreed out p. st) stated that peo- pie with t t tuberculoAis s auld not drive--dyen. e'vehicles. ap At's' 1,vith:6_,-4iphys ma and peicst arsubject to disabah-gtaclq--of 4 ;Sho41c b e itated\on an iiv dua basis and in li ht` ,o the :type tet drive Canadian dical ciation, 1974y: s'ilually safe for :people clerk° per marien tracheotom follow:mg:a y,;ingectoiny todiek 7resAri d-weight i e valti 1 but not Public dnev (Cadiaii Medital kssocition,- 1974; Qu be y f .of-Transport, 197 3 ; Americatilg,dieat_ _A spoeiatton 1-9,S8,-, Nova Scotia Medical Socidty, -l965). HoWevere, peoplyiiili injuries or deformities of the mouth oc r,?at Which serf- -. . . , ously interfereiwItil breathicannot safely operate any-type. of motor-vehicle 4 r':3 = '-' ' -(Canadian. MedicaLTA s s ()elation, 1974; American, l edical,A ssociation, -1968)., 13.. Adrenal Disease People with adrenal cortical hytp rfua?.ction-LCusbing's di4ease) who develop muscle' Weakness aiid osteoporosis .should not drive any type of vehi-

cle.If they \irikprove,, with treatmenti the,mail-be able to_ J.,4-Ive priVate rno- tor vehicle. s.(catia4raii. Medical A ssociati n, 1974; 'Quebec Ministry of !Trans-7 port, 1974; Ame`ricancMedical Association, 1968; Nova 54.0tia Medieal Society, 1965):- ; nts with-Addison's disease, particillarly thbse With asthenia or lo* blood.1 pressure should be advised not to drive aMotot vehicle k. unless theymptorris are, milci and well centrolled by herapy, in which ea.ie they.rmay brate a.private motor vehicle only. (Canadian Medical Association, 1974; Amer can Medical Association, 1968; Nova Scotia Medical Society, 1965)A

o Hyperfuriction of the adrenal medulla due to-the development of a pileo- chramocytorna with paroxysmal hypertension, headaches, dizziness, and blurred vision is ,a contraindication to the, operation;., of any type of motor vehicle until these symptoms are completely relieved by the removal of the tumor.(Cana7 di = n Medical-A ssociatinn, ;1974; American Medical A asodiation, 1968; Nova tia Medical Society, 1965), oid Disease People who suffer fro rn thy_i to xicosts, bec use.of theco-existenCe of cerdiac and emotional d,isturbances,_shAid-not-be allowed to drive until

their. disabling symptoms are well controlled (anadian Medical A ssoCiation, s_1974; Waller, 1974; Quebec Ministry of Transicirt, j973; American MediCal A ssociation, 1968; Nova Scotia Medical: Society;,1965),, Also,those people'', with severe rriy-x44emia or cretinism should not be licensed to driSre.The' ria. tan Medical-Association (1974) suggested that individuals with-rny-xederna oa.b drive if therre spond. to treatment.People`Who have enlarged thyroid glands with preg.sure symptoms can be licensed to -drive private but-not -Corn-7 Mereial vehicles (Canadian-MediCal A ssociation, 1974; -American Medical Association, 1-968; Medical Society of Nova Sotia; 19E55); 15: Parathyroid Disease P ogle with hype rparathYroi&isrn who suffer from muscular weaves and by of n- a cannot drive.. If the symptoms are benign and treatment 0- sat es- factorythey may\ be authorized tb, drive in--iv ate'Avehicles.(Canadian Medical Assoc on, 1974; Quebec Ministry of*Tran'snort1.973; American Medical Association, ,l968; NoAra,,Sedtia Medieal Society, 1965). A cute hypo arathyroiclism accompanied. by Resift)uscular excitability .--- re de rs people unfit for driving.The affliction must-be e amined on the basis_ __

' of the seriousness orthe Symptains. When: it is benign and does not show ob.- _ Vious signs oftetany,', the pes-son can drive private vehicles.

16.Pituitary Gland Disease People suffe from diabetes insipidus could safely clii4e private ir, ciess'iong, asithe re no sign of a-disorder of the visual apparatus or central . nervousyi_temIf such symptoms exist, driving is forbidden. (Canadian Mecli

cal AssocLion1974; Quebec Ministry, of Transport, 1973_.;__ American Medical Association, 1968; Nova;_iScotia 'Medical Society, 1965).- When hypopituitarisrx. suited in pie.ribds O f spontaneous hypoglycemia, the patient= must be advised not to drive at all.If treatment iS,Suctessful and the patient is= followed closely by physician, he can usually sarfely,dtive private -ehicles.(Canadian Mddi,L1 Associati on, -074; Quebec Ministry of Transport, 1973 ;4American Medical Association, 1968). , tents With acromegaiy who have begun to develop muscle Weakness, pain, easy.fatigue, visual, disturbances, cardiac 'enlargernenfOrintractable theadaches cannot drive any tyke lof vehicle safely(Canadian. Medical Association, :1974; ArrieKican Medical A ssociation,_ 1968).

YGander, (1966) in a study of drivers with chronic disease only Z. 570,of drivers with renal disorders had accidents, and 7.7% o group of normal drivers had accidents. It wast felt that with' chronic renal failure Who- reqUire n I mittent... _ dialysis but who are !otherwise. in good health, can drive aprivate motor !vehicle'and. li=ght c ornme r cial or public=transport vehicles safely pro- . ti vided they are always_ able to be dialyzed at the interval recommended bytheir physician.This means that, at) the present time,\' such personsmust lin--iit their driving .t,O about threehiindred miles from librrie in order to avoid undue fatigue and- providea margin Ofsafety for, unexpected delays.Due_allOwance also-must alkvays be-made for 'delays'that May be caused by-winterdriving condgionss-.--- (Canadian Medical Association, 1974). 18. Cancer One factor that is often overlooked as a cause of collapse during driving was, carcinoma- of the bronchus `V:thich commonlymetastasizes in the bra.irr and may cause seizures. However, Ma.rkel (1975)_the'Arnerican Cancer Society reported there has been noproblem with the licensing of cancer patients. The cancer patients are either obviouily too sick tQ' drive (and they, do not) or they are completely able 'tip drive

9.Obesity

, ,Ari_e_; emely obese person may not be able, to respond rapidly enough art emergency,----: situation_ and may not be able to operate the controlsin a smaller ar,properly -(Canadfan Medical A seociation,, . 1974)., Obesity could also constitute -.--, a handicap fdr a person re!aired, to drive acommercial vehicle.The exertion needed-in cditi-urie rciaf drrVing nay be hazardous to the obese driyer(Quebec Min-. -istry of TranSport,,?977.30 4 . Autoof daptive EOUipme The Easte yzed Veterans As oeiat en reported that as of 1961 an ated one-third f three million seriously handicapped drivers ufteed adaptive controls (American Medical Association Sournal, 1971).There are certainly more in use today.Mach' (1971) found hat in a selected group of 100 physic. disabled persons 95 were able to drive with appropriate changes in the auto-;- mobile...s However:: Hyman dt al, (1972) concludegign a review of the literature that available adaptive equipment allowed a limited group of the disabled to drive. ',From a stristly technological almost any physical disability could be accommodated; however, economicpracticalityand need limited the development to the most useful ada,ptive eqUipment (Peizer, 1975). The'Americ ri Automobile Association (1972) produced a catalog of manu;; facturers of automobile adaptive equipinent. \They also rectimrnended which types of adaptive controls, were used.for Various types of disabilities; beTiere dictes, and Dougherty (1975) have catalogued several hundred special transporta; on vehicleS.or assistive devices available forthelanclicappecl.This directory ers a brief description of the device, its operation; its cost, and pther ,ice.- portant_statistics_Rodger (197E4 _presente&a_chart with the type ofadaptive' controls needed for various disabilities as well. as the-type of general vehicle' equipment needed.l.,..auvie (1973) describe-d., in general terms, vans for the physically handicapped and presented a listing of manufacturers a Wheelchair lifts, hand controls, ',ramps, etc.Scott (1 974) described the te-of-the-art in safety for modified vans. - The President's Committee an Employment Of the Handicapped recommended a partial list of requirements for a.utomobikes:

Door opening of 36" high. Ellus admit wheel hair. Removable headrests to enahle,dr r to .bring i.n wheelchair... :f 13- width n, back seat a rate rgency brakes and Wind sh.ers. Front seat .S WM. 0 on enghto act as grab-b doors wide enou h for easy access to the front seat by the par ple-gic, and trunk -and door he,ight at a convenient level for a pe-rson in a who elchail-. Two-door clsign Automatic transrni Poker steering Power brakes, Tilt steering wheel (Power seat Power w_indotws Electric door locks Anrm rests (right?id center Inside adjustable mirrors. Bench seats Citizen's band radio Rear windoW defroster 'Electric garage door ope side rail sling tfor'llfting echanical lift' (van. Wheelchair locks Contoured cushion seat Inside overhead grab-bar Sliding door Small ramplfor whe Seat .rail Extended seat guides Another author Gresbani (1974), added several aaditional require the list above: ucket seats console._ Pivot front seat

Zorman and kiinger (1970) presentedan overview on transfer of the physis- cally-handicapped into automobiles, automobile safety aids and a.ccessciries, parkingan\-%-garages, Atornobile controls, and adapted vehicles, as_we kl. as tra.- vel considetier's_ for the handicapped driver.Zino (1972), in his article, des - cribed the rriLnirnurn car requirements for instructing physicallyhandicapped students. ,_----' - . , Mere were a rninks._ fcrn the physically handicapped. tt akland 975) - and Harden'an, ,'Ten is ood (1973) point e 4 out tilt handicapped'personsc'.be automobile' motor Brdblern in trouble w4ith power equipped vehicles if they have. Many do not have ,the strength tohandle the.ve, withou ass s He rectunmended aback -up power system. Thereereipt, ,any re'searoh stiydi es 4re's. of adaptiv controls and drivel. behavior, GoodwiLl (A F4) sti.died the reaction times "of .30 normaland., 50 dilsabled persons': foUnd-that the., di s able d reaction time s -for Movement f foot from accelerator to brake and Moven-lent of handfrom wheekto'hand brace e r.; P;ichtei-andymarf (1974) found tb..4.t a.group, of 15 drivers could activate Vccultroll and'a pistol -grip controller With trigger'titivated drakes fastdi afoot-oPeratext brakes.In a somewliat'controllid study Ws.sh gt WState (Hyman, 1974.663 hand control drivers had equivalepit ?eel- dent and Violation rates whentrip ared to 104 nonrest2icte 'driver Peizer (1975) -discussed his knowledge of-the state -Oto -art of advanced. adaptive 'eqpikanent concepts. .lie.qesaribed a Vehicle. control usingemoveMent of the eyebrows and the adaptive devices, a litter patientCould use to drive,;`; Bray and Cinviingh.am (1'967)described theerieral need for -develoPment- of vehicles for diff exent critical levels of spinal.cord,functiort. _ . 6 Huddleston et al.. (1957) presented L. case where a patient with very limited upper extremity function was able to driVe'his car mddified with: all 'foot controls. Kesterson (1975),described a special 'driving .ring for amputees inoplaCe.of`tlie typical spinner knob on th'e steering wheel': They can open their hook .nil insert it in the ring.Reynolds (1975)- designed,a'driving splint for,support of thO arm or quadriplegics not requiring the use of the triceps,Several possibilities for rnotoriied controls were pre sexUed in Lehneis et al.(1.969).Dunke/ and-SelRyn (1975) described their. "Open-Loop Electric Steering System" for cars "and.vans that allowed reliable stee ring through fdot switches. Harden and Tenniswood (1973) describe:ii controlS Which bypass the normal pedals and connected directly to the servo'-valire of the brakesystem' and to the carburetor.These controls were designed for handicapped individnals who lack, the strength'and range of triotion required to use the add-on typeof adaptive controls. Almost all of the force required to operate thefinger controlled brake comes from the vacuum power unit.This push button device gave eal feedback for aid in the control of the vehicle.

-94-- Fr man (1974) reported that in .1970 Congress authorized purchase of ptive autorriobile driVing aids for disableiviterans. stett17 control ystenis 'and,found that only five were safe.Peters (1973) repolted' that 17 different band-contr91systems were purchased art tested.They were.re 4 jected becatre of safety hazards or generally 19w qUa4ty. He mentioned that installation was a highly specialized job requiring general autornetive me n- icaLknowledge and specific nrdetstanding of the 'control,systelin.Na spec cations;-' standards, regulations or-Sequiremetsn Were in existence in the V. E. at file writing ,of-this article.Tentative kederal standards for automotive adap-. tiV'e equipment for disabled veterans were! published in 1975 (VeterOns Adrnin s® t ration., 1975).These standards-established Safety specifications, -operations rements, a.nd reliability standards comptments 6f.the se devices The biggest problem for the wheelchairrbound-Peeson was-getting into and

the car- (Goldberg, 1975).Dick: aLtA Gresham. (1974) described a proce- dure for getting a Wheelchair into a,tvio-door car.They recommended two4 door iiitornobiles Over four-ddror models because of additional room for enter ing acrid exiting.Goldberg and Davii,(1967) also presented a technique of lifting a wheelchair into a two-doer vehicle by a paraplegic. unningham (1971) described the development of a special wheelchair which was a.-dapatable to a .twt -door sedan, and among othir things, could climb curbs. A description of,the desiin and operation of an external.hoistfor wheelchairs which mounts on the i roof of a ivehicle-wa,s presented by Henshavi (1970).Rozin. and NolnaiL(1971) delscribed.now a specially designed wheelchair aild reconstructed . a automobile were used to enable a .triplegic .patient to drive.Deyoe and Ander- (1970) reported the development of a iransfer stool which assists quadriple-, gisin getting from theirwheelchair's to the automobile driver's seat; 1..r?Engla.nd; Hall (1960) noted that the use of adaptive controls an ErIglish cars with manual transmiissons:was. an-un§atis a-ctort' modification for persons without uie of legs.Controls for the invalid:car (three-wheNied) were designed, for the handicapped.However, these cars are underpowered, unstable, and noisy. Millicamp (1970) also discussed the problenis with Englandra poorly designed,inv-alid cars.Another' article described some improvements of tbe'controls of the invalid car (Three-Wheeler Conversion Helps the Disabled, 1969)., DW °akin (.1970) .suggested__I that the Rritish Milli Car was a,'acti solutioresince9. hancicofitrols are easily fitted, and there was room for a ,heeichair. He reported. that the Wni, was better suited for the physically handica ped t American. automobiles. A reaction to 4, mini mar with adaptive contis was a.lspresented Thisection'iclentifiehe most irn ant addiiior-ial research and de velophaent efforts' needed in drier educ tinri and licensing of the handicapped These recommendations Were dentified.duringsthe performance of the pro)ect and represent Suggestions,froraboth Phase I and a of the program.: The-order in which they are preeented,doesnot ind.icate preference or iTriportanc&". A mor comprehensive analysis he thi7.Tin'g task for normal drivers.Of particular interest are those situations critical to 'fe driving.- With a detailed analysis of the'perceptual,cogni- tiv-e, and motoraspectsutilized in cirivixig, it Ivould allow for a ore valid determination of the effects of medical disabilities on driving.

Detailed analysis: ofdriving for various kiaridiCappecl drivers. This would be adeterminationof those cornpensa_tory driving behaviors that are.different from the ablebOtlied.. From a comparison of normal and handicapped dri-;:rer requirements for the handicapped fdr skills dAvelopin.ent could --be-dete-rrnined. A separate analysis,vould be/required for each disability.

largescaleeipdemiological type study to measure the accident and violation rates of specific handicapped groups. To date, most -epidemiological type studies havenotdefined their popula- tionssufficientlyto draw meaningful .conclus ions. A detailed study -would ineludespecificmedical diagnosis for all members of the study and specific details abouttheindividualinthe stiady- samples (e.g., drilling exposure, sex, driving .enviroarnent, types of-vehicles,drivertraining 4tc.-)

Validated procedures for the assessment evaluat_ of each handicapped group. These procedures would be f9r: Acceptance into a driver education program Personal evaluation of capab of driver education needed (full or cond Re-licensing (after haVing been-ltcensed prev Development of cific medicaLcri eria that validated. The o ld be used as a basis-for:

'DeterIna- applica_ilts are alled to drive a Bete f conditional license. between license Development of driver ecducatio9a.l Materials. These would 'be designed for use in public ichOol, rehabilitation institutions, private driving sc;hoolS and others.The following are the types of educational packages that would be developed: rriculurn materials for each of the various handicaps .g., materials for -the mentallyretarded, the epileptic, those Oith.cardiovascular disease, the orthopedically impaired, etc. Training package to teach techniques to driver educatti personnel (both special education and dri4er training instructors) Training package for achOol administratorso that each- ing_ programs for the handicpped can beesablishe Different_prograrns for the new driver ,remedial Mg, and for the newly handicapped driver Development of educational materials and-,programs related to the licerAing and education' of handicapped drivers.These could .- take the foci of complete programs, or 'simply, booklets. The following are the types of persons for whom-these programs could be developed: pkciaiists IL the Di y (IDLE, DIA,- and-others)

DiViy. administrators s

, '1?"-ate -phy sic--5 and vabficealth. people : .,-.. Medical_advisory board.participants

-9 ncl, I g_ pe

o e neia blie

andiCap h selves Legislative, s ns tor veiaclespectors ergency dic 1. irsonne:l Speaal interest grou Establishing and implementing. an improved educatioand"lkeneing system.:.' This would inclydeollectin.g.data to evaluate and improve the system itself.

Establishing and running aclearinghouse,. for information. on handl capped drivers.ThiS clearinghouse would be, a central repository for all the research fields that contribute to this area,

Q. Study the potential effects of therapeutic drugs.. This would bethe clevglopment of a catalogue of available information on all therapeutic', drugs And the possible effects, can driving,,This-could also include e4- , yerirneritation to ermine specific effects. Studying the use of and establishing'a conditional licen-seprdgra..rn The principal interests of the study would be the legal, implement tion:.enforcerrient, and cost implictithis of a useful conditional licensing program-. Deyelopment and validation ora driver pe ancv hest, valid driver pei-formance test could be used for both theable-bpdied'and the handicapped, alike. VI.

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Burg, T.. 1 b., Light, W. O., & Douglass, Li Ligensin deaf driver. Arch Otola ng, 1970, 91(3

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California, State of, -Loa:Angeles City ,11-4fied School District.': Driver eduation cdurseof study for EMR studehts. Los Angeles, California, 1970'.

Campbell, 0. F. & Ellis,'K. C.. Chronic medical- conditions and traffle violation and accident experience of diabetic drivers. Modern Medicine of Canada, 1969,,24(11), 29-31.

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C2.

7,, APPENDIX A

FOUR GUIDES TO THE LICENSING OF DRIVERS WITH CARDIOVA GULkR AND CIRCULATORY DISEASES

-139- Nova Scotia Medical Society., Committee on Traffic Accidents. Nova Scotia guide far physicianin determining fitness to drive a motor vehicle,The Nova Scotia Medical Bulletin, May 1966, 3-12.

Appraisal must be made cif the extent of damage of the valves and to the derangements in rhythm, paitilar likely to alter suddenly, and to the efficiency of the myocardium.

W An marked is prone to lead tongina, syncope and sudden death.Pa7 tients with severe aortic stenosis should be advised not to operate a motor vehicle,Patients with lesser'degrees of aortic stenosis without symptoms should be advised not to operate a pa.s5enger transport vehicle but may operate a commercial or private motor vehicle Patients h aortic insufficiency and left ventricular failure and dyspnoea or par?xyrn.al nocturnal dyspnoea should be advised not to operate a motor .vehicle.. 'Patients with a lesser degree of aortic insufficiency without dysphoea should be advised not to operate passenger transport vehicles but may operate a cerninercial or private motor vehicle, Patients with myocardial isisuff, ciency due to mitral stenosis or insufficiency .should be advised not to operate a commercial or passenger transport vehicle brat may continue to operate a private vehicle when the myocardial failure.if any, is well controlled, Suba ute baCteriar endocarditis necessitates .mediate treatment abstinence from operating any motor vehiCle. auriculdr taclayeasa, flutter or fibrillation and a rapid ventricular e, unless cont-rplled,case severe incapacity and should be regarded as contr Andlcations to operating anmotet' vehicle.However, when these disorders of rhythm are well controlled, such -patients may operate a private Mo- tor veh;s6,e.Because of the workload and the stress on the heart and because of the danger of ernholization, patients with auricular fibrillation should be advised not to operate a commercial or passenger transport vehicle.

-140, Disease.

Hyperterts.1,0 itself is not disabling for safeoperationlofa motor vehicle, but the complitons arising fromhypertension--i.e., damage to brain, eyes, Heart or kiclne ay well prove to be disabling.When complications of hypertension are d to the optic fundi the degree ofLtnpairment of driving ability should he evs.l,uated solely= the basis of lossof visxvn,.If there is evidence of cardiac damage- resulting in Congestiveheart failure or angina pectoris, such patientr.should be -advised not to operate anyMotor vehicle unless the congestive failure or angina is well controlled 'bytherapy, then the patient may only operate a private motor vehicle.The level of the blood pressuremust obviously be interpreted the light of itS eonstancy.,,, -The patient's sex andthe patient's 4e, as well as the degree of complications, must beassessed, - before any de- CiSiOli is made to restrict driving ability onblood pressure figures alone. Fixed hypertension without complications isnot acontraindication to operating a private or con=ercial motor vehicle. Heart Disease If sclerosis of the coronary arteries hasresulted in angina pectoris and these attacks are mild, infrequent andcontrolled with therapy, such patients may still drive private motorvehicles and light, commercial but notheavy 'commercial and passenger transport vehicles,,- More s angina, even if accompanied by varyingdegrees of heart block, ventri -Premature contractions or arrhythmias, if'well controlled by therapy, d not prevent the operation of privatemotor vehicles.These` patients sho not opepatecornmerCial or PaSsenger transport vehicles. Sever ought on with little effort should beonside ed a con ale- dication to the r per Lion of a motor vehicle. The patient w acute coronary thrombosis should beadvised that he should 'not operate any sport vehicle for at'least two niOnthsfollowing the attack. Assessment thereer would be dependantupon the presence or absence of congestive circulatory failure or severe -anginapectoris..

Patient ic aortitis having syncope, congestive heartfailure, or angina pectoris, shouldbe advised not to operate a motor vehicle,unless these symptoms are well controlledby therapy, in which case it is permissi- ble that they should drive a private vehicle butnot a corritnercl or passenger transport vehicle.

-14 gins of rn.yordial insficiency are preset such patients should be ad- wjs d tact to operate a cornmeial or _passenger tranport vehicle but ,may op- vte rate a private vehicle. Heart Disea ymptornatic congenital heart lesions are notontra-indications to safe- drivin Patients developing signs of myocardial insufficiency should be ad to operate a con-Ismer aal or passenger transport, but may operate a i.vate vehicle as long as their signs remained controlled by therapy.

Patients with right sided heart failures secondary to diseases of the lungs 0 be advised not to operate a commercial, or passenger vehicle.However, symptoms of right ventricular failure, are mild and well controlled by such patients may operate a Private motor vehicle.

npatient with an arterial. aneurysm, because of the danger of rupture, e advised not to operate a motor vehicle..' I r-Ceriovenou;' fistulas re- severe heart failwe -constitute a contra - indication to the operation otor vehicle.Both conditions may be amenable to surgte.. al treatment.

acute phases of the pericarditis; patn.ts under therapy are unable operate any motor vehicleViral pericarditis das not constitute a con- s. Lon to the operati, r,cif a motor vehicle, once the acute phase has Patients with ehro i,a.constrictive pericarditis may operate a pri- vehicle, if the condition well controlled,, but should be advised n t ePate commercial 'or passenger transportrvehicles: ent with inadequate blood flow to the brain,' h.aving attacks of synco

mess shciuld be advised not to operate a motor.Vehicle. there has been . any ebral vascular episode 'causing changes in personality, alertness, ability to tn.a.ce decisions, or',if there has been actual loss of motor Or sensory poi.ver or cc:I-ordination, ,such patients shbuld be advised not to operate a motorvehicle. However,(, if such changes in AlractiOa are mimmal, with little or no disability, it ma.y be possible for these individuals to drive private motor vehicles.

nts with thrombophlebitis or previous thrombophlebitis resulting In the extremities and impairment of use should be advised not to atecommercial or .passenger transpolt vehicle, and if sufficient disability they should be advised not to drive a private motor vehicle.Patients with tive vhlebothi:'ornbosis should be Advised not .to drive a motor vehicle be eau Of dange r of 'embolism. rdiac Enar3 err ent Enlargement ,of the heart should not initself by considered a contraindica- to the operation of a. motor 4:ehicle but such erdargement points to the pre- f organic heari disease, which deserves appropriate evaluation. Cardiac R 'degrees of impair unction-of the 'myocardium should not be d a''contraindication to the operation of a private or lightconarriercial vehicle-, 'b-dt may not orera.te a heavy CoMmereial or passenger motor vehiek-.If Myocardial insufficiency is more marked, the patient should be cautioned, against the ope raticon of a light conuriqrcial motor vehicle ait is_ likely to prevent proper °performan.ce under emergency conditions.' if corige,s, tve beaxt failure is well cont'r'olled, suchpaiienis` may operate private -Irotor vehicles only.

A ias and Conduction Aurtculpremature beats are of little cohsequence and do riot preclude operation of motor vehicles: ients with paroxysmal auricular tach-7 ard4, flutter or fibrillatiOn with inyo'cardial insufficiency should be advised 0 operate commercial or passenger transport vehicles.; 11, however,. tacks are well controlled by therapy., than the pa.tifritmay operate a

-143- light commercial or private motor vehicle-only.Auricular fibrillation of the chronic nature provides the risk of ,emboliza.tion from the auricles.Such patients should therefore; not operate'a commercial or passenger transport vehicle but may 'operate a private motor vehicle if well controlled ny therapy. Ventricular arrhythmias other than occasional ventricular extra systoles are usually associated with heart disease. Such patients should be advised not to drive commercial or passenger transport vehicles but.may drive private vehicles if well controlled by. therapy: AuriculoVentricular block in a minor degree is of no significance.The patient with prolonged degrees of arterioventricular block or complete arterioventricular block, if associated with syncope (Strokes-Adams syndrome), should be advised not to operate any motor vehicle. If these attacks have been well controlled by therapy for one year or longer BUch7patients may, operate a private motor vehicle. ljypotensioll Hypotension in itself is not a contraindication to the operation of a motor vehicle.If, however, it results in attacks of syncope, such patients may operate a private motor vehicle.If hypotension is preseht and is considered to be related to symptoms Of dizziness and or syncopal attacks it should beassessed in the light of the seriousness of the underlying disease process. Carotid Sinus Sensitivity Individuals with carotid sinus sensitivity who experience attacks,-of syncope should be advised not to drive a motor vehicle-If-after therapy the patient is cured this decision should be revised.

-144, U.S. Department of Health, Education, and Welfare, Public Health Service.Driver licensin: !uidelines fo edical advisor boards relating functional ability to class of ve e.Public Health Service Publication No. 1396, 1969.

Heart Didease (Table Z Acute myocardial infarction is the most common medical cause of sudden death behind the. Wheel.Th it represents 'thethe severest kind of driving im pairment, it accounts for only a small proportion of highway accidents.Lesser degAkes of acute coronary insufficiency may cause transient alterations of consciousness and anginal pain that can be distressing enough to result in significant impairment of driving ability.The level of consciousness May be impaired by two separate and distinct mechanisms. The first of these is. inadequate per- .fusion of the brain secondary to a mechanically impaired heart.The second is impaired ventilatory capacity of the lungs secondary to heart diseased'. This lat- ter category, often called dyspnea, may be caused by primary lung disease, but this will be considered separately. -ORGANIC HEART DISEASE AMA A CEPTABLE LEVEL OF l -'131TCTION FOR DRIVER LI ENSURE

LU Group Passenger. Cargo Private transkort . transport auto ree (Individual consideration) ye s es no no yes yes yes. _no no safe-no) no no_ (Individual consideration, based on risk) Time to be set by evaluation of advi Organic heart disease is divided into three groups. ou_rth group with certain .arrhythmias. Group A--A driver is in Group A when:

(1)he has asymptomatic heart disease, a and the single or double Master's Two Step Test does noproduce- sy-mp- toms, or alterations of the EGG, and

' V prolonged exertion, emotional stress, hurrying, hill climbing, recreation, or daily activities doxlot produce pathological symptoms, and

(4)signs of congestive heart failure are not present Drop B--A .driver is in Group B when he ha one or more of the following: alking one to two level blocks, climbing one flight of stai performance of usual activitie-s prothices symptoms, or Master's Two Step Test produces sympterns and_ECG changes indica- tive of anoxia, or emotional stress, hurrying, hill clirnging, recreation or simi tivities Produce pathologic symptoms, or gns of congestive failure, if present, are Group C--A driver is in. Group C when he has organic heart d symptoms at rest, and one or both of the following:

) The performance of any of the activities of daily living beyond the,,per- honal toilet or its equivalent produces increased discomfort, or ins of congeive failure, if present, are resistant to therapy. GrouD - -his group includes individuals with cardiacarrliyth unias. While some of these ailments, such ashronic asyrntomatic atrial fribrillation, usually do not present notable airments, otherssuch as paroxysmal atrial flutter do present a high of catastrophe.Hence, consideration mus.t'be based on their risk fac rich can be arived at only by eyalu- ating each'disease entity. Cardiac Individuals with iinplanted pacemakers to control heart. rate should not drive cargo or passenger transport vehicles.. They may reasonably be permitted to drive private_automobiles, if given a medical review at 3-month intervals by a physician familiar with cardiac pacernakers.

1--jy_eilar Disease _(Table 3) Hypertension, because of its effects on the brain and other organs of the body, is of importance with respect td driving ability.A repeatedly elevated

-146- diastolic pressure eve.-0 mm Hg. in an untreated individual is, for purposes of these guidelines, assumed lo be diagnosis of hypertension.Transient headaches from this disease must be judged on an individual basis to determine their severity, frequency, and subsequent interference with the individualls driving ability. Table 3. HYPERTENSIVE VASCULAR. DISEASE AND A CCEPTA BTX, LEVEL OF FUNCTION FOR DRIVER LIGENSURE

II III. rviw 11% Group Passenger Cargo Private Periodic Limited trans ort ans *art auto reevaluation license yes yes yes yes no B no ne yes ye s no C no no (Individual' ye s (Individual consideration consideration) usually unsafe) no (individual no consfaeration)

Group ADiastolic pressure repeatedly over 90 following: abnormalities of urinalYsis nary function to ensive ce rbrovas cular damage; evidence of left ventricular hypertrophy, or hypertensive abnormalities. of the optth fundus, except for minimal narrowing or sclerosis of arterioles."../(Keith-Wagner Retinopathy, .60 Stage I). Cr ii - -A repeatedly elevated diasolicpressure over 90 n Hg. and., any one of the followth

I., (1)proteinuria and abnormali iein the urinary sediment but no impairment of renal function; history of hypertensive cerebr vascular damage without residuals;

-147- evidence of ventricular hypertrophy,

4)definite hypertensive changes iT-r the retinal arteriole without r ges.. (Keith -Wigner Retinopathy,--- Stage 11).

Gr 'repeatedly elevated :diastolic pres u over 9Q a any tVio of the following: t- diastolic pressure usually in excess of 120 rnm proteinuria and abnormalities in the urinary sediment, with evide of impaired renal function; hypertensive 6e ebrovascular damage with permanent neurole gical residuals,

left ventricular hype opliy;_

retinopathy of arterioles,. with. hqrrhages and exudates. Wagner Retinopathy, Stage III). croup D--ktepeatedly elevated diastolic pressure over 120 tung. and ariy two of the following: lic,pressure usuallY in tlfe range of 140 mm Hg or more; proteinuria and abnoilnalities of the urinary sediment with evidence of nitrogen retention; 4. hypertensivCerebrovascular damage with permanent neurological impairment, .left ventricular hypertrophy;

(5)rethiopathy of arterioles with papilledea.,Keith-Wagner R`etno- ,pMitiy, Stage IV)

ascular Disease Affec thexre_ es (Table 4) gk The importance of this category toc'the ability to drive safely depends on impairment of the functional use of the affected extremity or extremities. category is divided into three groups.Presence of vascular disease is presumed to have been diagnosed by existing conventional methods. Loss of pulses or arterial calcification is not considered an impairment to driving. Table 4. VASCULAR DISEASES AND A CCEI5TABI.F, LEVEL" OFFupCTION FoR DitrvER urENsuRE

II V enger Cargo Private Periodic Li or transB auto evaluation license

.., yes yes yes, yea no . no no yes year rn0 r- no : no (IndiVidua. .no no consideration)

up A driver is Group, A when he has vascular disease an experiences neither Intermittent claudication nor pain at- .rest, or aces only transient-edema. Group -B--A driver is in Group B when Re has vascular disease one of the.following; =

(11,- :ant claudication occuring onalking more than 25rds; s- cul`ar damage evidenced by healed amputation of any n er of digits of one extremity or amputations at or above the wrist or ankle of one-extremity with evidenCe of persistent vascular disease; healed or persistent superficial ulceration, and moderate to marked edema which is Only partially ontrolled.by elastic supports. group-C71% n group C when he has vascular` disease with 'one of the following: intermittent claudication on.walking less than 25 ya or severe "and

constant pain at rest; . vascular damage evidenced by amputations of a e dig of two extremities, with perSistent vascular disea persistent, ad, or deep ulceration involving any number extremities. A rter al and arterio-venous aneurysmS must-,be considered separately since they =ray not produce symptoms that interfere with,:drivin.g. -Sonic of the e atieurysrns, however, do, have a high; risk of rupturing.Therefore; they represent a serious danger, as they May cause A catastrophe. Each case should be given individual consideration."die following recommendations are intended to be very general: , Fertioral. and Fopliteal Aneurysms use disorders usually are .associated with prodromal sympton'is that warn the driver of impending diffieulty.Hence, drivers are 'usually able to avoid dangerous situations if complications develop. PerdonSwith such conditions ,should b'e advised that long periods of, sitting are dangerouS to the drieurysin.After such advice, however, they slicitild be able.to drive private. automobiles safely, They should net be recommended for 1.tcenies to-drive cargo= or passenger-transport vehicles. ._ Aortic and Central Nervous System Aneurysms, These vascular disorders present a very high risk and drivers of all types of vehiclesshould be given a careful individual evaluation of past history.In general,. such individuals usually should not _be recommended for. cargo and transport licenses. uebec y of Transport.,ediCalguide.to determine o drive a motor vehicle.Department of Transport July 1973.-

seases`o e.a r 04-s' ular S

1. General Rena rk He-art disease doenot rnself or by definition preclude drivi However,: -its h are intrinsic, depend on the degree of fu_ncL tional impairment resulting from the cardiapathy anaAcow effectively iriedical or 'surgical therapyestablishes a satisfactory cardiac ,outptt and controls-cer-: risk-entailing factors. Heart Failure- Whatever its etiology, heart failure entails a suta.h.tial and Often sudden decrease in the Cardiac output, which renderscardiopnaths unfit for drying motor vehicles.Such d'restriaion can be modified, however';. the cardiac insufficiency can be corrected by surgery orby.effectiye, controlled cardiotonic treatrnent.The New York Heart Association Nornenclatule, which sugges,ts four, class.es of functional ilicapacity, can be used as abasis:

I. A symptomatic patient-, -II.Symptomatic patient .d.,a.ngprolonged exertion III. Symptomatic patient dl_inemild ere _ion IV. Symptomatic patient at rest Theoretically, those classified I or II can be fit to drive all types of rotor vehicles except buses and vehicles weighing more than6, p00 pounds. Those classi.d m can be fit to drive private yehicles s ith restric- Lions H, J, K and L. Those in clas are considered .,urtfit to drive motor vehicles.

Since, :Ely definiti ,heart diseases are progressive and the state of cardio-circulatory ,restitution of limited duration, periodic check-ups ofthe cardiopath must be mad once a year for cardiapathic drivers ofprivate vehicles and every six months for those licensed to drive publicvehicles. Reports of these examinations must be sent to the MedicalDirector of the ]Motor Vehicle Bureau once or tivice a year, as required.

-151- What is true of valvidar cardiopathy also applies tofengendtal cardiopath. Cyanosis can be measured only by the functionalresults of a thoibugh heodynarnic exarniNtion.r:' This also holds true for congenitalaortic.'stetridsil and,hypertrophic muscular stenosis of the left ventricle..The siiggested fund- tio41 class4fication should be use&as a guide for the evaluation of these heart diseases' (see "Heart Surgery" #12). A cute' or Progressive Cardiopa.thy

,_ rdippathy in'the acute or progiesve stagabsolutely j precludes

ardiomegal'

Cardiomegaly, n.at .disease as ,soich., is often a manifestation of primary-(far4ly, aLcoholid, and so forthi.or Secondary (sa.rcoidosis,hemochroma-, tosis, and so on) -cardiornyothpay.Asses&ment 'of cardipmeg aly... depends on the etiological eleTni involved, the 'impairment of the cardiacoutput and the potential dangeetionr-ofndu,§4 and , rhythm disorders.Generallyf-spealdng those affli-. ctediwith cardiornyopathy- are only fit to drive private vehicleswith a maximum curb weight.of 6-0.00- pounda- ed Valvulara.rdopa.thy All recommendations concerning the,fitness fordAving_,of people afflicted-with valvular carcliopatlay must bebasedon the fundtional effects ofthe lesion and its progression.t The New York Heart AsiociatiOn Nomenclature can be used as a guide tosymptomatic aortic stenosis, which, becalise it can cause sudden loss of consciousness or syncope, precludesdrivi-ng.

Igeneral, isolated a-r_rhythinia, whiclids not related to acardiopathy, vehicles.Su- doe;not render people unfit for driving private or public motor. praventricular par6XySnlal arrhythmia (supraventriculartathydardia, flutter and paroxysmal fibrillation) must not increase and must bekept under observation if a person is to be declared fit for driving a6,000 pound private vehicle. Conduction Interference

A. s le first de red atrioventrictaar blbck, which is not related to proessive rnyopathy, does not preclude drivin.g public orprivate vehicles. Second degree atriove..ntricular blricks aid congenitalthird-degree blocks, when perman6rit, asymptomatic and related tafa sound ventricular .rate,,nee¬ preclude driving private vehicles.It must be .rernemberedthat such conditions. en- tail.the danger of fainting spells; consequer(tly, thesepatients must-be reexamined every year.Total atrioveiatricular blocks arid Ada:ms -Stokesdisease priecliide driving.Those:who wear electronic pacekers may be declared fit for drivihg pri;raie vehiele.gr lorlig as the condition and he effgctiven'ess:of thepacem4kers are checked at leastevery three months. ,

_ . 9. Coronary Dis ase A person who has s i_ffered miyocait infection must not drive for two months following' the a:ttack.No tient o has -suffered from myocar7 dial infa:rction can be considered fit fordrikring paSseerrig. buSes or ambulances. If the patient does not haVe anginal attacks, Ifhii,hgart rate is not abhor-Mal and he does not suffer from cardiac insufficiency, .may be granted a. chauffeur's permit for, all other public or privatevehicleS whocurb weight does not exceed -ix mbritheto the Medi- 6,000 pounds. He must submit a medical reporteery . II-,he holds an operator's-permit, how,, cal Director of the Motor Vehicle= Bureau. = . ever, he need do so only'once ar year. , ,- ., any patient in th.e early stages of anginal syndr iie or ,a period o vious'aggravatiOn must be considered unfit for driving. 'Stabilized anginal syndrome does:not precludedrivin 10. Arterial Aneurysm All'aneurysms Apf-the major arteries, particularly.of.the aorta, can -cause sudden death arid therefore precludedriving unless-thy are successfully corrected by Surgery.' Once thiS has been done, licenses caneventually be granted for private vehicles whose; curb weightdoes not exceed 6, Doti potmds. 11. I-Iyiaertension Asymptomatic hypertension and hypertension which responds tomedi- ciCtion do riot neca'sgarily preclude 'driying. _ Duyingthe initial phase othypo- .t tensor treatment and until the -symptonishave, beensta.blized, patients shotAld be ,advised no-to drive. People with pathologic blood pressure can usually onlyhold an-operator's permit for private vehicles_ with a maximumcurb weight of 6, aoci pounds; they rnust submit a medical report. to the MotorVehicle Bureau ery rear. (A) Surgery to correct conge dia.c or vascular defec When such congenital malformations are totally and permanently cured by surgery, those afflicted may be considered, cured'and issued chattf feur'spermits.

(B) r. cry common types under this classification are; Com issurotoy.foritralenosis: unless there are progressive symptoms, Patients who have undergone this oper7- ation can usually be issued chauffeur's permits. Valve replacementPeople with replaced valve can driveas long as they doiicit.::sUffer frorn,heart failure, arryth_mia, fainting spells or angina pectoris.

Whether the surgical technical was Arineberg' s operation_ or-An oronary shunt, the same criteria as for myocarflial infarcti61:1 41-31y.

ConclusiOn For all diseases, under the heading "heart diseases, " except 'where ted otherwise, chauffeurs' permits can be issued as well as operators' fits,. but they bear restriction "H", that is; the curb weight of the ehicle must not exceed 6,000 pounds.

Disease ebrovasculaS st erebral Ischernia or, arteriosclerosis of safe for people to drive if they.are subject to dizziness or - syncopes as a result of intermittent vascular ischernia of the brain or cerebral arteriosclerosis. Cerebral Hemorrhage or Infarction It is riot safe for people to drive if they have had a: cerebral hemorrhage or infarction,ith a behavioral disturbance.If it is a minor.disturbance, they

154- can, howeve ate vehicle imum curb weight of 6,000 potmds. Tighe' cerebral damage has resulted in impaired motor activity or coordination, the ivib Vehicle Bureau examiner must report to the MediCal Advisory Committee on the person's behavior on the road.The Committee will then rnake- its decision in light of themedical report and that ofthe ex- . Canadian Medical Association, CoMraittee on Emergency Services. Guide for physicians in determining fithess to drive a motor vehicle. OttaVa: Canadian Medical A s s °dation, 1974

RDIOVA SC LTJ.,A R PISEASkS'

The ROle -ardiovasctilar Dis.eas There is a lack of conclusive statistical data about the_imiortance cardiovascular .conditions as ..a. causative factor ji-i.motor chicle. a.cciden.fs. However,, -'.its. felt that a physician can usually give a valid me (Hear opinion as to the probability of sudden-death, lOss of consciousness, pain-or weakness sufficient to cause loas of control- of a vehicle. Ks with other disabili- 'tie s,. the drivers of passenger carrying and commercial transport vehicles are expected to meet higher standards of fitness because of the extra demands put on thern. 4.lAcute Cardiac Inflamma Applicants with acute pericarditis or Myocarditis -should not drive any type of motor .vehicle until they have made a full recover=y.Applicants with subacute bacterial endocarditis are also unable to drive any type of motor vehicle safely until they are completely well because of the, danger of embolism

4. Z- Gouge al Heart Defects Asymptomatic congenital heart.lesions are by themselves no cont cation .to the operation of any type of motor vehicle.- Applicants with co a- tive heart failure or other symptoms arising from suchtdefects.should be assessed on the basis of the complications present. 0111 the symptoms can be well controlled with treatment, an applicant can usully drive a private motor vehicle without difficulty but cannot usually drive a passeriger transport or commercial vehicle (Class 1,2, 3 or 4 license ) safely because of the extra exertion ofte. n required. 4.3 sclerosis Heart.Divease

a)Angina Ri.ctoris--Applicants with mild and infrequent attacks of. angina pectoris that always respond well to therapy can usually drive a private .motor vehicle safely but should not drive a passenger transport or coMmercial vehicle of any type because of the extra exertion frequently dernah.ded'in their operation.Angina, which occurs while the applicant is at rest and angina which readily provoked by the effort required to maneuver a motor vehicle in a sudden emergency or by the annoyances of day-to-day driving, isabsolute_. contraindication to sir type of drive g until_reViewedAay aptiropriati sp

(b)Myocardial Insufficiency -- "the oedeina anddyspnea--dri exertion resulting from impairment of-function of the I--nyocardiurn isMinimA the applicant can usually operate a private Motorvehicle safely-.If the dysPnea Coiries -so marked that it affests.the performance'Of the usualduties invsaved irihe operation.of a Motor vehicle or is likely to prevent properpkforrnanOe in eergeney,-M the. applicant'should not drive any type of motor Vehicle,if 'the _coriaeotive heart failure can be controlled by therapy, the applicant can driving a private motor vehicle, but should not operate a- , senger transport or commercial vehicle (Glass1,Z, 3, or 4 license

(c)lviyocardial IfilarctionApplicantS who have had a _nlyceartital, arc-. tiorrshould.not drive for at lest eight Aveeksafter clinical recovery ajudge by their:plysician.It is felt that aPpliCanta-Who have-had a- provenrnyo-Cardial, infa.i-ctio&annot thereafter'operate a large passenger transport or heavy con ercial vehicle (Glass I and 2 license) safely betause the possibility of apecond :aretion while- on duty is srAficanticr-increased: Applicants who have sad two rata ctions,should, not thereafter operate taxicab, ambulance, mailer el- bias (Glass 4.1iCense).

emature Beat prem. ture beats are Of little - consequencePr.1t and' in tine a pence o briormalitfes ldb n ireelude the safe on of any tyke of motor vehicle.

(b)sParoxysm..1 Ta,c1-4;-cardia--Paroxysmal auricular tachycardia is usu ally wiimportant and only rarely lim4fs physical ability.Paro4tanial':tachycardia or. ventricular origin,' on the other hand, frequentlysigliifies tIrgallTc heart disease of a serious nature and persons -with thisconditioklCannof safely operate any type of motor vehicle until theunderlyfnVcause ha-s-been detern-iined and- corrected.

(c)A ricular Flutter and Fibr Ilation-Apphcanti with chronic auricithr flutter or fibrillation can usually drilze a private motor, vehicle safely, provided their ventricular' rate is contVolied by treatment and they do not have -some other serious underlying cardiac condition.Since persons-with chronic a-uriciilar flutter Or. fibrillation. May ,develop emboli, it is felt unsafe for them to drive passenger transport or heavy commercial vehicles (Gla.ss I,2,,3, or 4 licenoe (d)Bradycardia and Heart BlockSinoauricular bradycardia and congen- auriculoventricuri} block, unless of marked degree, are usually of no signi- axice.Applicants found to have auriculoventricular block should, however, he assessed on an individual basis.in younger persons, not acutely ill, even high grades of-auriculoventricular blo6k may be compatible with full activity.In older persons, heart block is more serious even in slight grades.If symptoms are well controlled by treatment older applicants with even a relatively marked, degree of block can usually operate a private motor vehicle safely, but should never operate a passenger transport or commercialvehiele (Class 1, Z 3 or 4 license). 4.5Carotid Sinus Sensitivity Applicants who become faint or lose consciousness when they are subject to carotid sinus pressure cannot drive any type of motor vehicle safely.If their carotid sinus can be made less sensitive, such applicants 'can drive a private motor vehicle safely after a period of observation to assure that the condition has stabilized. 4.6Hypertension Hypertension otlier than uncontrollable malignant hypertension, is not by itself a contraindication to the.operation 'of any type of motor Vehicle but the complications that can arise from the condition, such as damage to the heart, eyes, kidneys and brain, may wellpreVtiit safe driving.Persistent hypertension .above 170/110 is frequently accompanied by complications that may make driving dangerous and applicants with a blood pressure in this range must be .examined very carefully.If the eyes are found to be affected, the degree of impairment of driving:ability will depend on the loss of vision.If the hypertension has caused cardiac damage resulting in congestive failure or cerebral impairment, this' should be the principal consideration in evaluating the ability of the applicant to drive safely. Higher standards should be required of passenger transport and commercial vehi*cle drivers than of drivers of private passenger cars.If the blood pressure is found to be 130/100 or more in such applicants, their evaluation should include an electrocardiogram, chest X-ray, fu_nduscopic examination and akiN, and they should be referred to an internist for an opinion if a marked, de ion from the normal is found. Applicants who are found to have hypertension and.who are p'laced on drug the -ropy should not drive any motor vehicle until their response -to treb.tment has been observed and any ne -0Ssary- adjustment to their medicatioli-has been made. 4.7Hypotension Hypotension is not a contraindication to the operation of a motorvehi however, it resuats in- attacks'of syncope, such patients cannot safely oiler- atany type of motor vehicle,If it is possible to controlrhe° syncope fully by treatment, the applicant can then usually operate a private-motorvehicle Safely but should not drive a transport or heavy-commercialvehicle (Class 1, 3, or 4 license).

4. Aortic Valvedjisease ree of s yamp- Applicants Frith minimal aortic valve disease, ,Who, ar ton-is can -operate any. type of motor vehicle safer' svere disea-se, es pecially-aqrticstenosis, .may cause. unexpected ss, dizzihess or even syncope.Applicants with such sympt e any ty-p6 of passenger transport or commercial vehicle sa .-3 or 4 license and must be evaluated on an individual basis to ;T.:mine etherthey can safely operate a private Vehicle., Applicants if should be folloWed up regularly to ensure their .c'o .---:d.fitness.to drive

4.-9 Cardiac Pacemakers Applicants who have had .a cardiac pacemaker imPlairted can_uaallyd. a private motor vehicle' saly when this apparatus. has-shccessfully relieve them of their symptoms for a peniod of at least one-vo.onth,)providedthey ar regularly attending a pacemaker, clinic Or are being'speri?Py their own phy.si- Ian at least once every threemonths.' Such applicantS:cannot, however, drive passenger transport or commercial vehicle(Clags or 4 license) safely;, because- pacemakers, (Vliile they are becoming incresingiy'reliable, are still sifpject to unpredictable failures. 4.10 Prosthetic Valves Applicants' who have iad a prosthetic valve iilserted are subject to e boli and to a lesser extent to failure ofdie valve meChanism.',4).oh applicant can usually operate a private yriotor.vehicle safely provided'their prosthesis Was successfully controlled their uncierrying cfa rdiaccondition.They should not, however, drive passenger transport or heavy commercial. . vehicles(Class 1, 2, 3,'1-4 license). 4.11 Anticoagulants The use of these drugs is not per se a aindication to driving.the patient be assessed with the underlying ess in mind.

71 9 Although the future may dictaie that these patients are capable of handling all types of motor vehicles, at the present it is suggestedthey they should not operate a commercial vehicle (Class 1,2, 3 or 4 license).Their ability to operate a private vehicle must be assesse Y. very carefully.(Class 5 only).